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DISl'.ASI.S    OF    THE    EAR 


A    TEXT  BOOK 

FOR   rRALTITIOXHRS  AXD  STrDRXTS 

OF  MFP/ClXf': 


\:\ 


EDWARIl    HKAnroKI)    DFvNCM.    Pii.  B..    M.  D. 

PMurBAMlM    ••»     •        • '■     '      .......     COLLKGE  ; 

AV«a:  iHK 


MBOICAL  SOCimr,   BTC. 


WITH   EIGHT  COI.ORKD   PLATES  AND 
ONE  Ht'SDRKU  AND  HKTY  TWO  ILLUSTRATIONS  IN  THE  TEXT 


N  K  W     \'  ( )  R  K 

I) .    ,.\  P  I'  L  L  T  O  N     A  N  U     C  O  M  I'  A  N  Y 

1S9S 


Copyright,  1894, 
Bv   D.  APPLETON   AND   COMPANY. 


Electrotyped  and  Printed 

AT  THE    ApHLETON    PrESS,  U.S.A. 


PREFACE 


In  the  preparation  of  the  present  work  it  has  been  my  aim 
to  adapt  it  to  the  needs  both  of  the  general  practitioner  and 
the  special  surgeon.  For  this  reason  minute  pathology  has 
not  been  considered  extensively. 

In  detailing  the  various  manijjulative  procedures,  I  have 
preferred  to  err  on  the  side  of  prolixity,  for  the  benefit  of 
those  not  familiar  with  the  subject.  It  has  also  been  my 
purpose  to  keep  constantly  before  the  reader,  the  fact  that 
many  diseases  of  the  ear  should  not  be  considered  by  them- 
selves, for  the  reason  that  they  are  often  local  manifestations 
of  systemic  condition. 

Many  works  upon  otology  have  failed  to  emphasize  the 
importance  of  a  thorough  functional  examination  ;  and  none 
have  placed  the  results  of  recent  investigations  at  the  disposal 
of  the  reader  in  such  a  manner  as  to  enable  him  to  use  them 
in  diagnosis.  In  consequence,  I  have  written  at  length  uj)on 
this  subject. 

In  advocating  operative  procedures  upon  the  middle  ear 
and  in  devoting  much  space  to  the  subject  of  middle-ear 
operations,  I  am  aware  that  I  shall  not  have  the  supjjort  of 
many  distinguished  colleagues.  As  a  careful  reading  of  the 
chapter  will  show,  1  iiave  written  from  personal  experience  ; 
and  if  my  results  differ  from  those  of  other  operators,  I  sug- 
gest that  the  selection  of  cases  suitable  for  operation,  accord- 
ing to  the  principles  detailed  in  previous  chapters,  may 
account  for  the  favorable  outcome  of  the  operations. 

In  illustrating  the  gross  pathological  lesions  of  the  con- 
ducting mechanism  and  the  various  manipulative  measures 
instituted  for  their  relief.  I  have  adopted  the  plan  of  showing 
the  auricle,  meatus,  and  middle  ear  in  the  same  drawing.  The 
drawings  are  of  natural  size,  and  the  technique  of  the  various 
procedures  seems  to  be  made  more  clear  in  this  manner,  than 
by  any  other  method. 

(iii) 


IV 


PREFACE. 


In  the  colored  plates  of  the  membrana  tympani,  the  adja- 
cent portion  of  the  meatus  is  also  shown,  thus  reproducing  as 
completely  as  possible  the  picture  seen  upon  speculum  exami- 
nation, and  rendering  the  relative  position  of  the  parts  more 
intelligible.  In  this  connection  I  desire  to  express  my  indebt- 
edness to  Dr.  W.  A.  Holden  for  the  careful  manner  in  which 
he  prepared  these  plates  from  clinical  cases.  Without  his  aid, 
these  illustrations  would  have  been  impossible. 

The  absence  of  extensive  bibliographical  citations  may 
seem  a  defect,  but  in  a  work  intended  as  a  clinical  guide,  a 
complete  bibliography  would  be  impossible,  and  unless  com- 
plete it  would  be  useless.  No  attempt  has  been  made,  there- 
fore, to  collate  the  entire  literature  of  any  subject,  and  the 
citations  have  been  limited  to  those  necessary  to  give  indi- 
vidual investigators  the  proper  credit  for  their  researches. 

It  gives  me  pleasure  to  thank  the  \V.  F.  Ford  Surgical 
Instrument  Company  for  the  care  which  they  have  bestowed 
upon  the  illustrations  of  various  instruments  and  appliances 
which  appear  in  this  volume. 

17  Wkst  46TII  Street,  Nkw  York  City, 
October  to,  iSg4. 


C  O  N  T  I :  NTS. 

SECTION    I. 
THE    ANAIOMV    ANH    IMIYSId'"  N     <>!•     lid     KAR. 

CHAPTER    I, 

PACES 

The  Anatomy  of  the  Ear 3  47 

The  auricle— The  external  meatus— The  bony  meatus — The  tym- 
panic cavity — I'lie  ossicles — The  intmtympanic  ligaments — The 
membrana  tympani — The  epithelial  investment  of  the  conducting 
apparatus — Intratympanic  folds — i  he  muscles — The  arteries — The 
veins — The  lymphatics — The  ncr\-es — The  bony  labyrinth — The 
membranous  labyrinth — The  saccule  and  utricle — The  membranous 
cochlea— The  vascular  supply  of  the  labyrinth — The  auditory  nerve. 

CHAI'TER    H, 
The  Physiology  of  the  Ear 48-72 

Sound — Function  of  the  membrana  tympani — Function  of  the  ossi- 
cles—  Function  of  the  muscles — Function  of  the  cochlea  ami  semi- 
circular canals — KtTect  of  tympanic  changes  upon  the  labyrinth — 
EfTect  of  stimuli  upon  the  auditory  nerve — Reflex  phenomena — 
Secondary  phenomena — Hypcmesthesia  and  pancsthesia. 

CHAI'TER    HI. 

Physical  Exa.minaiion 73  '4' 

Preliminary  observations — Source  of  illumination — The  Reflecting 
Mirror — .Specula — Technique  of  Examination — Appearance  of  the 
meatus  and  membrana  tympani — Obstacles  to  examination — Tym- 
panic trpography — Politzerization  —  Catheterization — Auscultatory 
sounds — Obstacles  to  catheterization  —  r)angers  of  catheterization — 
The  examination  of  the  nose  and  throat — The  history. 

CHAPTER    IV. 
Functional  Examination 142-170 

Quantitative  tests — Qu.-\litative  tests — Rone  conduction — Differential 
diagnosis — Precautionary  measures — Irregular  phenomena — Special 
tests — (ialvanic  reaction  of  the  auditory  nerve. 


vi  CONTENTS. 

SECTION    II. 
DISEASES   OF    THE   CONDUCTING   APPARATUS. 

/.  DISEASES   OF   THE  AURICLE. 
CHAPTER    V. 

PAGES 

Congenital  Malformations  of  the  Auricle        .        .        .  173-182 

Deformities  of  particular  parts  of  the  auricle — Deformity  or  malpo- 
sition of  the  entire  auricle — Auricular  appendages — Polyotia. 

CHAPTER    VI. 
Wounds  and  Injuries  of  the  Auricle 183-186 

Contused,  lacerated  and  incised  wounds — The  effect  of  intense  cold 
— Burns — Injuries  due  to  the  action  of  chemical  substances. 

CHAPTER    VII. 
Cutaneous  Diseases  of  the  Auricle 187-199 

Intertrigo— Eczema — Pemphigus — Herpes — Syphilis — Lupus. 

CHAPTER    VIII. 
Inflammatory  Affections  of  the  Auricle   ....  200-205 

Perichondritis  —  Erysipelas — .Xbscess — Othajmatoma  —  Thickening 
of  the  lobule — Ossification — C.angrene. 

CHAPTER    IX. 

Benign  Tumors  of  the  Auricle 206-212 

Fibroma — Lipoma — .\iheroma — .\ngioma — Cystoma — Papilloma. 

CHAPTER    X. 
Malignant  Tumors  of  the  Auricle  and  of  the  Meatus.  213-216 

Epithelioma — Sarcoma. 

//.    DISEASES  OF   THE  EXTERXAL   AUDITORY  MEATUS. 

CHAPTER    XI. 
Circumscribed  External  Otitis 217-237 

Acute  CiRcuMSCRiiiKD  Kxtf.rnai.  Otitis  or  Firinclf,.  .'Etiol- 
ogy— Pathology — Symptomatolog)- — Diagnosis —  Prognosis— Treat- 
ment— Bloodletting— Cold — Instillations — Heat —  Incision — Inter- 
nal medication.  Chronic  Circimscribed  External  Otitis. 
Significance  in  diagnosis  of  mastoid  inflammation. 


CHAPTER    XII. 

Diffuse  External  Otitis 238-266 

Chronic    Dipfise   Extern.\l   Otitis.     Etiology — Pathology — 
Superficial  —  Cellular  —  Desquamative  —  Parasitic — Consecutive — 


CONTENTS.  vii 

PAGES 

Symptomatology — Diagnosis — rrognosis — Treatment  of  the  various 
varieties  of  the  disease.  .Vitte  Difki'sk  Kxtkrn.vi.  Otitis. 
yEtiolog)- — Dependence  upon  the  chronic  form — Pathology — Symp- 
tomatology— Diagnosis — Involvement  of  middle  ear — I'rognosis — 
Treatment — Local  depletion  —  Irrigation — Cold — Incision.  Croup- 
Ol'S     AND      DiPHTHERllTC     EXTERNAL     OTITIS.         ll.tMORRHAGIC 

External  Otitis. 

CHAPTER    -XIII. 
Impacted  Cerumen 267-278 

>Etiolog)' — Pathology — Symptomatology — Direct  and  reflex  phe- 
nomena—  Diagnosis — Prognosis — Treatment — Use  of  the  syringe — 
Use  of  the  curette. 

CH.APTER    XI\- 

Foreign  Bodies  in  the  Canal    .        .  279  284 

/Etiology — Pathology — Symptomatology —  Di.igiio-is —  Prognosis — 
Treatment — Removal  through  the  natural  passage — Removal  by 
external  incision. 

CHAPTER    XV. 
Exostosis  of  the  External  Alihtory  Meatus   .  .  2S5-290 

/Etiology — Pathology — Symptomatology —  Diagnosis —  Prognosis — 
Treatment. 

CHAPTER    X\  I 
Wounds  and  Injuries  of  ihe  Memhrana  Tn.mpani  291-295 

.•Etiology — Pathology — .Symptomatolog)- —  Diagnosis —  Prognosis — 
Treatment. 


///.    DISEASES  OF   THE  MIDDLE  EAR. 

CHAPTER    XVH. 

Tubal  Ciin(.estion',  or  Tuhal  Catarrh 300-312 

ittiology — Pathology — Symptomatology — Diagnosis — Physical  ex- 
amination —  Functional  examination — Prognosis — Treatment — In- 
flation— Dilatation — Medicated  vapors — Prophylaxis. 

CHAPTER    XVI II. 
TUBO-TYMPANIC    CONGESTION. — TUBO-TYMPANIC   CATARRH         .    313-322 

/Etiology — Pathology — Symptomatology — Diagnosis — Physical  Ex- 
amination— Functional  examination  —  Prognosis — Treatment — In- 
flation—  Incision — Internal  medication. 

CHAPTER    XIX. 
Acute  Catarrhal  Otitis  Media 323-335 

/Etiologv' — Pathology — Superficial  structures  alone  affected — Symp- 
toms in  afiults — .Symptoms  in  children — Inspection  of  discharf^e — 
Diagnosis — Physical  examination — Functional  examination — Prog- 
nosis— Treatment — Depletion — Dry  heat — Instillations — Incision — 
Irrigation — Topical  applications. 


viii  CONTENTS. 


CHAPTER    XX. 


PACES 


Acute  Purulent  Otitis  Media 336-350 

/Etiology — Pathology — Involvement  of  the  connective  tissue  in  the 
vault  of  the  tympanum — Secondary  involvement  of  the  lower  por- 
tion of  the  cavity — Extension  to  bony  structures — Symptomatology 
— Evidences  of  mastoiil  involvement — Evidences  of  extension  to 
the  cranial  cavity — Diagnosis — Physical  examination — Bulging  of 
membrana  tlaccida — Functional  examination — Prognosis — Subse- 
quent functional  condition — Chronic  purulent  otitis — .Ma>toid  and 
intracranial  involvement — Fatal  ca>es — Ireatment — Depletion — 
Early  incixion — Irrigation — Abortive  treatment  when  mastoid  symp- 
toms appear — Treatment  of  persistent  discharge — Drainage. 

CHAPTER    XXI. 

Chronic  Catarrhal  Otitis  Media 351-387 

General  considerations  concerning  pathological  characteristics  sep- 
arating the  cases  into  two  classe>.  (IIROMC  IlYrKKTRoIIIIC  (OTI- 
TIS Mkdia.     /EtiologA' — Influence  of  repeated  attacks  of  congestion 

—  ynresolved  acute  otitis — .MTections  of  the  upper  air  passages — 
Sex — General  condition  — Heredity — i'aihology — Tympanic  clianges 

—  Changes  in  the  drum  membrane — In  the  Eustachian  tube — In  the 
tympanic  ligaments — In  the  labyrinth — -Symptoinatoiogy — Hilateral 
involvement — Intermittent  character  of  the  subjective  noises  and 
impairment  of  hearing — Keflex  pain  referred  to  the  region  of  lingual 
tonsil — Diagnosis — I'iiy^ical  examination — Altered  position  and  den- 
sity of  menil)rana  tympani — Changes  in  the  apparent  Itreadth  of 
malleus  handle  from  rotation — Efiiision  —  Functional  examination — 
Impairment  for  voice  greater  relatively  than  for  shaqi  sounds — 
Changes  in  the  limits  of  audition — Condition  of  organ  secondarily 
involved — Prognosis  —  Duration  of  affection — Condition  of  upper  air 
passages — Degree  of  bilateral  involvement — Age — Secondare'  scle- 
rotic changes — rrcatment — Treatment  of  the  upper  air  pas>ages — 
Surgical  measures  antl  topical  applications — Of  the  Eustachian  tube 
— Inflation — Irrigation — l)ilatation  — Topical  applications — 0(  the 
middle  car — Simple  inflation — Medicated  vapors — Absorption  or 
evacuation  of  elTu-ion — Lavage  of  tympanum — Tenotomy  i>f  tensor 
tympani — Mechanical  support  in  relaxation — Surgical  procedures. 
Chronic  Hvi'kri'lastic  Otitis  .Media.  .ICtiology — Secondary 
to  acute  inflammations  of  tym]>anum  or  to  hypertrophic  inflamma- 
tion— Idiopathic  disease  resulting  from  systemic  causes — Occurrence 
in  one  ear  as  the  result  of  changes  in  the  opposite  organ — Pathology 
— Sclerotic  changes  in  the  tympanic  connective  tissue — Deposit  of 
new  connective  tissue — Changes  in  the  membrana  tympani — Depos- 
its about  oval  and  round  windows — Tension  anomalies  cau-ing  rot.a- 
tion  of  malleus  upon  its  long  axis — Changes  in  the  tympanic  vault — 
Labyrinthine  involvement — Condition  of  the  Eustachian  tube — 
Symptomatolog)' — Insidious  development — Subjective  noises  with- 
out impairment  of  hearing  —  Local  and  reflex  pain — "  .Auditory  fa- 
tigue " — Neurasthenic  manife->taiions— Diagnosis — Physical  exam- 
ination— Normal  appearance  of  drum  membrane — .\trophy  of  mem- 
brane— Malposition  of  ossicles  —  .Appearance  of  membrana  l1acci<la 
in  cases  secondary  to  a  hypertrophic  process — Functional  examina- 
tion— Variation  in  lower  tone  limit — Bone  conduction — Lateraliza- 
tion of  tuning  fork — Determination  of  relative  amount  of  tympanic 
and  secondary  labyrinthine  involvemen'  in  "mixed  "  cases  by  means 
of  tuning  forks — Changes  in  upper  tone  limit  and  its  significance — 
Prognosis — S]iontanoous  cessation  of  the  affection — Effect  of  mental 
anil  physical  exertion — Climatic  influence — .Age — Treatment — Of 
tympanum  ami  tube — Pa^sive  motion — Massage — Surgical  measures 
— Of  labyrinth — Internal  medication — EfTect  of  treatment  of  middle 
ear  upon  the  labyrinth — Hygienic  measures. 


IX 


PAGES 
8-415 


CONTENTS. 
CHAPTER    XXII. 

HRONIC   PL'RULEXT   OTITIS    MEDIA 

.•Etiology — Development  from  an  acute  catarrhal  or  acute  purulent 
inflammation  —  Tuberculosis  —  Syphilis  —  Pathology  —  Necrosis  of 
coniK  t-  and  osseous  structures — Caries  of  incus — Cause  of 

its  frt  rrcnce — Labyrinthine  involvement — Chantjes  in  the 

mast..,,.  — t  ..  .  v-^teatcm.! — Syniptomatolog)- — Discharge — Variations 
in  the  amount  of  di-ch.ir^e — Occurrence  of  aspergillus — Facial  pa- 
ralysis—Presence  of  granulation  tissue — Secondary  labyrinthine  in- 
volvement—  Diagnosis — Physical  examination — Classification  of  con- 
ditions Usually  found  upon  ins{>ection  and  their  individual  signifi- 
cance— Caric* — Use  of  probe — Significance  of  granulation  tissue — 
Displacement  of  the  ossicles — .\uscultatory  signs — Functional  exam- 
ination— Variat!  •  limits — Ffl'ect  on  ujiper  tone  limit — Bone 
conduction  — Fl  tion — Evidences  of  mastoid  involvement 

— Prognosis — P. :;^cl  upon  audition  — Cessation  of  discharge 

— Danger  to  life — 1  reatmcnt — Isc  of  syringe- — Other  methods  of 
cleansing — Treatment  of  the  upper  air  passages — Instillations — 
Powders — kentoval  of  exuberant  granulation  tissue — Irrigation  of 
vault  of  tympanum — Operative  procedures — Statistics  of  operations 
— Treatment  after  operation — Internal  medication. 

CHAPTER    XXIII. 
oTin.s  Media  Purulknta  Re.sidua 416-431 

AciJTE  Type,  ^ttiolopy — Identical  with  that  of  acute  inflamma- 
tion of  the  normal  i  '  '  '  — Hypenvmia  of  ex|)osed 
lining  of  tjnipanum  omes  purulent  by  infec- 
tion through  canal-  !  "v  necrosis  with  devel- 
opment of  chronic  ■  —  Interference  with 
function  —  Discharge-  i — Facial  paralysis 
—  Diagnosis — Physical  exam ui.ii ion — .^eious  discharge — Fxf<jliation 
of  superlicial  ej>ithelium — Thickening  of  remnant  of  drum  mem- 
brane— Signs  of  mastoid  involvement — I'rognosis — .Mild  cases — 
Severe  cases  with  retention  of  pus — Treatment — Mild  cases — Asep- 
sis—  Topical  ap]iliiations — Treatment  of  upper  air  passages — ke- 
moval  of  dead  Ixme  if  |iresent  to  prevent  recurrent  attacks — Severe 
cases — Inci-ion  of  menibrana  flaccida  with  cupping — Irrigation — 
Cold  to  ma.sioid.  Chk<iMC  Type.  Condition  one  of  increased 
tension — Secondary  eff^ects  on  labyrinth — Pathology — Classification 
of  conditions  found  in  these  cases — Symptomatology — Interference 
with  function — Presence  of  inspissated  secretion — Cholesteatoma — 
Pain  in  mastoid  due  to  sclerotic  changes — Di.ignosis — Necessity  of 
combining  physical  conditions  with  data  obtained  by  functional  ex- 
amination— Functional  examination — Evidences  of  incrensed  tension 
in  ci>nductirg  mechanism — Labyrinthine  involvement — Determina- 
tion of  the  degree  to  which  perceptive  and  conducting  mechanism 
isafl'ected — Prognosis — S|K)ntaneous  improvement — Age — Influence 
of  labyrinthine  involvement  upon  the  prognosis — Recent  and  chronic 
cases — Treatment — { General  measures — .Attention  to  upper  air  pas- 
sages .and  Eustachian  tube — Prophylaxis  against  otomycosis — Surgi- 
cal treatment — Ffl'ect  of  treatment  upon  function  of  opposite  ear. 

/r.   DISEASES  OF   THE  MASTOID  PROCESS. 
CHAPTER   XXIV. 

The  Anatomy  of  the  Mastoid  Process 432-438 

Variations  in  presence  .and  location  of  pneumatic  spaces— Location 
of  antrum — Relations  between   superficial  landmarks  and  cranial 
contents — Topographical  variations  dependent  upon  age. 
EE 


CONTENTS. 


CHAPTER    XXV. 

PAGBS 

Inflammation  of  the  Mastoid  Process 439-452 

Etiology — Secondary  to  middle-ear  inflammation — Idiopathic  cases 

—  Pathology — Sclerotic  changes — Caries  ami  necrosis — Purulent 
inflammation — Avenues  of  exit  of  secretion  —  Intracraiiiai  complica- 
tions and  channels  of  infection — Possibility  of  infection  through 
outer  surface  of  squama — Cholesteatoma — Symptomatology  —  Pain 
— Temperature  not  characteristic — Cessation  of  discharge — Evi- 
dences of  intracranial  involvement  —  Evidences  of  extension  of 
thrombus  from  sinus  into  internal  jugular  vein — Diagnosis — Local 
Icndemcss — Metho'l  of  eliciting  symptom — Involvement  of  meatus 
close  to  membrana  tympani — Evidences  of  external  rupture— Of 
rupture  into  digastric  fo-sa — Prognosis — Importance  of  early  recog- 
nition— Chronic  case> — Influence  of  diathetic  conditions — Cravity 
of  operative  measures — Treatment — Free  drainage  through  canal — 
Cold  to  mastoid  —  Irrigation  of  canal — Objection  to  Wilde's  incision 
— Early  and  radical  operation. 

CH.\PTER    XXVI. 
iNTRAiKANiAi.  CoMPiicATioNs  OF  Tympanic  Inflammation  .  453-462 

Otitic  Mf-NINcitis.  Manner  in  which  inflammation  extends  to 
meninges — Symptomatology — Variations  dependent  upon  location 
of  lesicn — Ocular  sym])toms  —  Diagnosis — Temperature — Headache 
— Vomiting — Prognosis — .Vdvisability  of  operative  interference — 
Treatment — Cold  applications — Internal  medication — Surgical  treat- 
ment. Sims  rnRoMiiosis.  .\vcnues  of  infection — Extension  to 
internal  jugular — Secondary  deposits — Symptomatology — Rigors  and 
sweating  — Intermittent  temperature— (ieneral  sejisis — Evidences  of 
second.iry  deposits — Diagnosi^ — \'alue  of  fre'|uent  thermometric  ob- 
servations— I  icner.il  condition  of  patient — Prognosis — .Apparent  re- 
covery—  Latent  cerebral  deposits — Tre.itment — ( >|>eralivc  treatment 

—  Medication — .Mimentation.  Extrai>iral  AliscESS.  Nature  of 
the  process — Symptomatology — Localized  headache  —Temperature 
changes — Mental  condition — Prognosis — Latent  deposits — Sponia- 
neous  evacuation — Value  of  operative  treatment — Treatment — Ne- 
cessity of  surgical  interference.     Ckrkbral  Ahscf.ss.     Origin — Site 

—  Latent  deposits — .\septic  abscesses — Symptoinatolog)- — Depend- 
ent upon  location  —  Constitutional  symptoms  —  .\sthenia  —  Sleejv 
lessness — Temperature — Di.agnosis — ( "ieneral  asthenic  Fymptoms — 
Sleeplessness — low  temperature — DiflTiculties  in  diagnosis  due  to 
complicating  lesions — Prognosis — Natural  progress  when  not  inter- 
fered with — Proper  time  for  surgical  interference — Results  of  opera- 
tive treatment — Treatment  —  Evacuation  by  operation 


SECTION    III. 
SURGERV   OF   THE    CONDUCTINC,    APPARATUS. 

CHAPTER    XWII. 
Middle-ear  Operations 465-514 

Prf.liminary  Preparations.  Instruments — Form — Construction 
— Sterilization — Field  of  operation — Necessity  of  asepsis — Mctho<l 
of  securing  an  aseptic  condition  of  the  parts — .\nresthesia — Limita- 
tions of  local  anaesthesia — Conditions  demanding  general  an.Trsthc- 
sia  —  Position  of  the  patient — Advantages  of  elevation  of  head  and 
shoulders.  Ci-AssiriCATKiN  of  (^PKRArioNS.  I.  Operations  upon 
the    Membrana   Tvnipani  —  Mvrintyotumv    for  cv.icuation  of  tluiil  — 


CONTENTS.  xi 

PACES 

For  depletion — For    explonition — Partial   myringectomy — Multiple 

inci>ii'ii  — '"  '"  -   involvint;  Section   of  Intra- 

tyin|;iiiK  icH'^or  tyni|>aiu — Methods  of 

•    ■    •  .  ..j;.iniciU  of  the  malleus — Divi- 

o  and  nonsuppurative  cases.     III. 
(  >_  r  <"!i,iiii — Kxcision  of  a  portion  of 

the   ni.iiuifnuni — iJi-  lization  of  the  stapes — 

I'lasiii  oprraMMns — K  — Technique  when  the 

iiirm'Tv  — 1  fcasmciit  alter  operation — Reaction 

I.H    «;:.  Kluction    of    the    ntemhrana    tynipani — 

1  ......     1     •  ,,yej — Ha-niorrhage 

nant  of  the  incus — 

'  ... —Subsequent  treat- 

r  of  <iisarticuiatt(in  at   the  incudo-stape- 

le  incus — Frequency  of  caries  of  incus — 

I  li.Liit<>riha|;<. —  iM^vihlt-    .icniitiiis — .Stacke's    operation — 

:iiy — With    intact    drum    nuinl>ranc — With   dium   niem- 

hruuc  J  .irtially  dcitrti>cd — Si.iiisiics  of  author's  operations  showing 

the  effect  ui>on  the  function  of  .^ti<li(iun  in  cascb  operated  upon. 

CH.AI'TKR    X.WIII. 

Thk  Mastoid  Oprration  5' 55-6 

Instrument* — I-  ition — Incision — Separa- 
tion of  stemo-  of  cortex — Kcmoval  of 
softened  \  < '■  ■  ;iig  of  lateral 
sinus  —  1  r  —  1  'ressing — 
After-trcT.:.., ,-  ■  ,  -  „  hildren— Tech- 
nique in  ma-toid  M.-ieroM» — 1  he  o|Kniiioo  lor  cholesteatoma — Berg- 
niann'»  o|Hrration. 

CH.M'TKK    .X.XIX. 

THK    Sl'ROU  At.    TRKATMKNT    OF    THK    INTRACRANIAL    COMPLI- 
CATIONS OF  Aural  Supfiration 5-7-533 


Incision  for  e^pon^rr  of  ^nns  mnf  nf  ivmpanum.  and  cerebellum  — 
rreaimeir  '     ijjular— Treal- 


Ii 

Ti 

mentnf,;  ,>— Operation 

.\f-   -  •  i  ocati'in  of  ex- 

pj,,,   ■  11  —  Fxploration 

of   ,  .              >    puncture  of 

ccr« '  '^f  lluid— Exploration  of 

Cfji-i  .  .\fter-treatmcnt  of  brain 
absccN — Ijc.iimciii  oi  i-iii^ka:  u.ci.ui-nis— Primary  operation  on 
mastoid— ExiKKurc  of  tympanic  roof—  Ex|>osurc  of  sinus— Dressing. 


SECTION    IV. 

I)ISF.\SES   OF    THE    FEKC  EPTIVF    MECH.\NISM. 

In  I  koi>r(  Tokv  Kkm.xrks 537-54° 

t  haracter  of  auditon,-  impairment— Comparative  value  of  physical 
and  functional  exaniin.ition — Importance  of  complete  history  Lo- 
cation of  the  pathological  process. 

CH.M'TER    XXX. 

;\N.KMIA    OF   THK    L.VHVRINrTl 54^-543 

/Ftiologv— Profuse  hxmorrh.ige— Constitutional  conditions— Symp- 
tomatolcJgy— Functional    impairment— Subjective    noises— Disturb- 


xii  CONTENTS. 


ances  of  static  function — Diagnosis — Physical  examination — Func- 
tional examination — I'one  limits  often  preserved  or  upper  tone  limit 
may  be  lowered — Deficient  bone  conduction — General  ana;mia — 
Prognosis — Dependent  upon  cause — Treatment — Stimulants — Ton- 
ics— Drugs  to  be  avoided. 

CHAPTER    XXXI. 

Hyper.«mia  of  the  Labyrinth 544  547 

/Etiology — (General  condition — Occupation — Concussion — Acute  or 
chronic  venous  engorgement  —  Pathology  —  Dilatation  of  veins — 
Extrava.satit)n — Serous  transudation — Symptomatology — \'ariations 
in  degree  and  persistence  of  the  manifestations — Diagnosis — Ab- 
sence of  definite  physical  signs — Functional  examination — Preserva- 
tion of  lower  tone  limit — I'ppcr  tone  limit  reiluceil — Impairment  of 
bone  conduction — Prognosis — Varies  with  duration  and  degree  of 
process — Treatment — Acute  cises — Depletion — Rest — Occlusion  of 
canal — Pilocarpine— Chronic  cases — Counter-irritation —  Pilocarpine 
and  the  method  of  its  administration — General  hygienic  rules. 

CHAPTER    XXXII. 
Labyrinthine  H.€Morrhage 548-550 

i^tiology — Concussion — Direct  traumatism  —  Blood  conditions — 
Change*  in  the  walls  of  the  blood  vessels — Diatheses — Pathology — 
Extravasation  —  Subsequent  changes  —  Symjitomatology  —  Prodro- 
mata — Sutlden  access  of  symptoms — Symptoms  usually  severe — 
Ciradual  abatement  of  manifestations — Recurrence —Diagnosis — 
Value  of  clinical  history — Functional  examination  —  Absence  of 
bone  conduction — .\bsolute  deafness  or  great  aiiiiitory  impairment 
— Upper  tone  limit  reduced  —Occision-il  disturbances  of  lower  tone 
limit  —  Prognosis — Varies  with  the  severity  of  h.xmorrhage — Static 
function  usually  restored —  Treatment — .\cute  stage — Depletion — 
Rest — Revulsives — Chronii-  ^i.u'e— Reduction  of  lahvrinlhiin'  pn-s- 
sure — Prophylaxis. 

CHAl'TER    XXXIII. 
Labyrinthine  Emboli.sm  and  Thrombosis       ....  551-552 

.Etiology — Metastasis — Inflammation  of  contiguous  structures — Pa- 
thology—  Results  in  local  anaemia — Local  necrosis — Inflammation  — 
Symptomatology — Function  of  organ  usually  not  much  disturbed — 
— Spontaneous  improvement — Prognosis — Condition  not  progressive 
— Treatment — Removal  of  cause — Reduction  of  labyrinthine  pres- 
sure—  Relief  of  subjective  symptoms — Stimulation  of  impoverished 
nerve  tissue. 

CHAPTER    XXXIV. 
Specific  Inflammation  of  the  Labyrinth     ....  553-556 

/Etiology — Hereditary  or  acquired  syphilis — Pathology — Chronic 
inflammatory  changes — Hypcrirophy — Changes  in  walls  of  vessels 
— Necrosis — Symptomatology — Sudden  access  in  acquired  form — In- 
vasion less  sudden  in  hereditary  cases — Diagnosis — Physical  exami- 
nation— Recognition  of  concomitant  tymjjanic  disease — Functional 
examination — Deficient  bone  conduction — Lowering  of  u]iper  tone 
limit — Diflferential  diagnosis  in  "mixed"  form — Prognosis — Intlu- 
ence  of  heredity — .\ge  of  local  process — Spontaneous  <|uiesccncc — 
Treatment — .Vntisyphilitic  medication — Pilocarpine — lodiiie  of  po- 
tassium— Strychnine  in  advanced  cases — Tonic  treatment  in  heredi- 
tary cases. 


CONTKNTS.  ^... 

CHAl'TER    XXXV. 

Inflammation  of   thk  Lahyrinth  sfxoxdarv  to  Chronic        ^''^^^ 
Suppurative  and  Nonsuppuraiu  e  Inflammation  of 
THE  Tympanum SST-qes 

Fatholopy— Inflamniator>-  changes — Atrophic  changes — Extension 
of'"'-      '■"  ■  mum— Con. iition  of  oval  and  round  win- 

do\\~  n — Functional  di>turbances — Symptoni- 

atoKi^.      -         .       — Sii^niticancc  of  di>ap])eaiancc   of  tin- 

nitu>— \  crtij;.)— >yn.i...ilK!\  i;i\. .h imcnt  of  opi)o>ite  ear— Diag- 
nosis—Thysual  ex.uniiiatiuii— Al.-eiice  of  physical  >igns  in  certain 
cases- Value  of  insjHrction  in  residual  purulent  cases— Functional 
examination- Kvi.!rnie<!  of  r>l>vtruction   to  sound  conduction- Ne- 

-I'etcrniination  of  relative  impor- 
liine   lesion — Klectrical   tests — Im- 
j'"'-''   '       1    •  11    iioth  sides  to  (letcnnine  secondary 

inv..!\tiiii  nt     .1  \     healthy    i>rj;an  —  l'rognosis— Residual 

purultiit  c.i-es  u  .-  l,„l  ^K,^^ly  or  not  at  all— Dangers  of 

sympathetic    iiivulvcn.  ment— Relief  of  cause   in    middle 

ear — I'reser^ation  of  .  \cd  secondarily — Special  measures 

directed  toward  labyrinth— I'lltHraqiine — Strychnine — Specific  treat- 
ment— I'crsislent  stimulation  by  sonorous  vibrations — Relief  of 
subjective  noises — Treatment  of  the  upper  air  passages — Danger  of 
treating  middle  ear  in  advanced  cases. 

CIIAPTKK    XXXVI 

Acute   Infiammmion   of  the   Labyrinth    secondary  to 

Acute  I'irulent  Otitis  Media 565^-573 

.l-Itiology — Ordinary  causes  of  acute  purulent  otitis  media — Viru- 
lence of  process — I'athology — Tissue  necrosis — Avenues  of  infection 

—  Infection  of  cranial  contents — Obliteration  of  labyrinth  from  de- 
posit of  mw  tissue  — S\m|)tomaicilogy — Not  characteristic  in  young 
subjects — l-.vuiiiites  of  labyriiuhine  infection  in  adults — Importance 
of  facial  ]ara!\  :  riiptoin  —  Disturbance  of  static  function — 
Retrogression  ii  — 1  l;vniorrliage — remianent  impairment 
of  audition  —  I 'i  r,  liiysical  examination — Not  characteristic 
of  labyrinthine  involvement — FIvidences  of  caries  of  internal  tym- 
panic wall — Functional  examination  in  children  unsatisfactory — In 
adults — I'pper  tone  limit  much  lowered — Hone  conduction  absent 
or  greatly  reiluced — N'ertigo^I'rognosis — I'nfavorable  for  comjilete 
restoration  of  function — Often  fatal  in  children — In  adults  not  as 
great  a  menace  to  life — Danger  of  absolute  deafness  less  common  in 
adult^ — Danger    of   causing    deaf-mutism    in    children — 1  reatment 

—  I'mphylaxis  against  infection  by  asepsis  from  the  tlrst— Relief 
of  tinnitus — Pr<x-edurcs  to  combat  extension  to  meninges — Cold 
locally — Purgation — Value  of  pilocarpine  after  acute  stage  has  been 
passed. 

CHAPTER    XXXVII. 

Involvement  of  the  Perceptive  Mechanism  in  the  Acute 

Infectious  Diseases 574-580 

Introductory  remarks — Direct  infection  of  labyrinth — Concomitant 
middle-ear  inflammation — Pathology — Inflammatory  changes — In- 
crease of  tension  by  efl'u^ion — Occlusion  of  vestibular  ami  cochlear 
aqueducts — .Symptomatology — Impairment  of  function — Tinnitus — 
Influence  of  age  of  patient  upon  manifestations — Resultant  mutism 
in  children — Diagnosis — Simple  if  middle  ear  is  normal — Determi- 
nation of  labyrinthine  lesion  if  tympanum  is  also  afi"ected — Value 
of  functional  examination  in  differential  diagnosis — "  Tone  gaps  " 


xiv  CONTENTS. 


— Prognosis — Not  grave  in  recent  cases — More  amenable  to  treat- 
ment in  children  than  in  adults — Treatment — Reduction  of  labyrin- 
thine pressure  by  pilocarpine — Strychnine  in  chronic  cases — Value 
of  persistent  education  of  power  of  audition.  Effkct  or  Certain 
Particular  Diskasks  of  this  Class.  Mi.mps.  Metastatic  infec- 
tion of  labyrinth — Prognosis  excellent  in  cases  subjected  to  medica- 
tion at  an  early  period.  Typhis  AND  Typhoid  Kk.vkr.  Probably 
causes  changes  in  cortical  centres — Usually  disappear  during  conval- 
escence. i:pH)r.Mic  Influknza  ;  Diphtheria.  Probable  involve- 
ment of  nerse  trunk — Ini]iairment  in  audition  for  middle  portion 
of  musical  scale — Tone  limits  unchanged — tialvanic  hypercesthesia 
— Bone  conduction  not  lost,  but  reduced — Treatment  directed  toward 
improving  general  condition — Valine  of  strychnine  after  acute  stage. 
Epidemic  Cerebro-spinal  Meningitis.  Pathology — Extension 
to  labyrinth  through  acpieducls — Inflammatory  changes — Extravasa- 
tion— Deposit  of  new  tissue — Secondary  invasion  of  tympanum — 
Symptomatology  —  Vertigo  —  Severe  tinnitus — Hyperacusis — Para- 
lytic symptoms — Diagnosis — Physical  examination  —  Negative  unless 
tympanum  is  secondarily  involved — Functional  examination — Pro- 
found impairment  of  audition — Ujiper  tone  limit  greatly  reiluced  as 
a  rule — Exceptions  —  Effect  of  hyperajsthesia  on  the  percejition  of 
low  notes — Bone  conduction  almost  or  entirely  wanting — Prognosis 
— Com|)lele  deafness  in  severe  cases — Significance  of  disappearance 
of  tinnitus — Danger  of  mutism  in  children — Treatment — Prophy- 
laxis impossible — Local  depletion  and  catharsis  in  early  stages — 
Pilocarpine  v.aluable  after  acute  stage — Cases  of  long  standing — 
Strychnine — Value  of  systematic  exercise  of  auditory  function  by 
the  use  of  conversation  tube,  etc. 


CH.M'TER    XXXVIII. 

Involvement    of    ruv    I'KRtEPnvE    Mechani.sm    in    Acute 

Meningitis 581-: 

Pathology — Labyrinthine  lesion — Involvement  of  nerve  trunk — 
Cortical  lesions — Sym])tomatology — Variations  due  to  location  of 
lesion  —  In  the  labyrinth  —  Subjective  noises — Vertigo — Impaired 
audition — Affecting  nerve  trunk — Interference  with  perceiUion  of 
middle  notes  of  musical  scale — Limits  of  audition  normal — Signifi- 
cance of  unilateral  impairment — Cortical  lesion — Bilateral  impair- 
ment— Won!  deafness — Later  symptoms — Diagnosis — Physical  ex- 
amination— Negative  frequently — Importance  of  rupture  of  mem- 
brane in  traumatic  cases — F"unctional  examination — Characteristics 
of  labyrinthine  lesion — Of  lesions  of  nerve  trunk — Of  cortical  in- 
volvement— Value  of  electrical  tests — Prognosis — Treatment — Acute 
stages — Pilocarpine  in  later  stages — Iodide  of  potassium — Strych- 
nine— Exercise  of  auditory  function. 

CHAPTER    XXXIX. 

The  Effect  of  Diseases  of  the  General  Nervous  Sys- 
tem UPON  THE  Perceptive  Mechanism  ....  586-: 

Cortical  Lesions.  Bilateral  involvement — Word  deafness — Audi- 
tory hallucinations — Intermittent  tinnitus.  Tabes  Dorsalis.  De- 
generation of  nerve  trunk — Calvanic  hypercesthesia — Perception  of 
middle  notes  impaired — Torpidity  of  ner\e  in  later  stages.  Lesions 
OF  Vestibi  EAR  Nerve  AND  OF  CEREBELLUM.  Disturbance  of  equi- 
librium—  Diagnosis — Dependent  upon  general  rather  than  special 
symptoms — Treatment — Value  of  bromides — Strychnine — Antisyph- 
ililic  medication. 


CONTENTS. 

SECTION    V. 

COMPI.ICATINC;    AURAI,   AFFECTIONS. 

CHAPTER    XL. 


XV 


PAGES 


Aural  Afffxtions  compi.u  AriNc    ihk  .Acl'tk  Infectious 

Diseases         591-593 

Affection  of  perceptive  apparatus — Involvement  of  conducting  mech- 
anism— Character  cictcrinined  by  ile^irce  of  infection — Portions  of 
tympanum  involved — Extension  to  other  regions. 

CHAPTER    .\L1. 

Aural   Affections   dependent    upon    Chronic    \'lsceral 

Conditions 594-601 

Symptoms  due  chiefly  to  circulatory  changes.  Nkthritis.  Kffect 
due  to  venous  obstruction — Arterial  sclerosis  and  impoverished 
quality  of  blocxl — Tympanic  effusion — Extravasations — Laliyrin- 
thine  hxmt)rrhaije — Ha-niorrhagc  into  nerve  sheath.  Mktastasis. 
Embolism  of  labyrinthine  vessels  from  remote  suppurative  process 
— Infection  of  middle  ear.  1  I  liKRilT-KSis.  I  ymjjanic  involve- 
ment—  Absence  of  pain  —  Multiple  perforation — Constitutional 
treatment  —  Effect  of  tympanic  process  upon  general  condition. 
LF.UC.tMlA.  Extravasation  into  labyrinth — I)epo>-it  of  new  tissue — 
Sudden  appearance  of  symptoms — Diagnostic  data.  1)iaiiktes. 
Frequency  of  inllammntion  in  external  meatus — As  predisposing 
cause  of  middle-ear  suppuration — I'-xtravasations  in  labyrinth,  nerve 
trunk,  or  centres.  (loiT  AM>  RllKi  matis.m.  Cutaneous  manifes- 
tations in  canal — .Arthritic  inllainmation  in  middle  ear— Changes  in 
the  blootl  vessels  and  the  results.  .Mkkicinai.  Si  iistancks.  Qui- 
nine— Effect  on  middle  ear  and  labyrinth — Salicin  and  salicylic 
acid — Conditions  contraindicating  their  administration — Tobacco — 
Effect  upon  higher  centres. 


CHAPTER    .\LII. 

Disturbances  of  Audition   dependent  upon  Functional 

Nervous  Disorders 602-607 

Unimportant  physical  changes  as  a  cause  of  manifestations  in  a  par- 
ticular region — Perversion  or  impairment  of  function  with  no  evi- 
dent lesion.  Ni.urasthf..nia.  "Auditory  strain" — Psychologi- 
cal effect  —  Character  of  impairment  of  hearing — (ieneral  sensory 
parrcsthesire — Diagnosis — Physical  examination  often  negative — 
Functional  examination — Perception  of  high  and  low  notes — Re- 
duction of  bone  conduction — Variable  results  obtained  by  succes- 
sive tests — Recognition  of  general  neurotic  condition — Ilyperacusis 
— Auditory  fatigue — Prognosis — Influence  of  organic  changes  in 
ear — Influence  of  general  neurosis — Treatment — Strjchnine — Bro- 
mides— Rest — Change  of  habit  of  life.  HYSTERIA.  Degree  of 
impairment — Sudden  appearance — Subsequent  course — Associated 
hysterical  paralyses — Transference — .\bsence  of  subjective  noises — 
Diagnosis — Sudden  onset — .\bsence  of  physical  changes — Cutaneous 
anrcsthesia — Functional  cxaniinntion — Contraction  of  range  of  au- 
dition— Upper  tone  limit  most  affected — .Mternate  variations  in 
upper  limit — Contraction  of  field  of  vision — Prognosis — 'Treatment 
— Attention  to  general  neurosis— Hypnotic  treatment. 

B 


xvi  CONTENTS. 

CHAPTER    XLIII. 

PACES 

Reflex  Aural  Disturbances 608-613 

Vaso-motor  changes — Trophic  disturbances.  External  Meatus. 
Reflex  inflammation  —  Cutaneous  hyperresthesia  —  Haemorrhage. 
MiDDLK-EAR.  Reflex  Otitis  media — Otalgia — Angioneurotic  oedema 
of  mastoid.  Perceptive  .Mechvnism.  Paresthesia — Influence  of 
visceral  disorders — Interference  with  static  function — Irregularity 
and  transitory  character  of  symptoms — Absence  of  local  cause — 
Presence  of  remote  lesion  —  Effect  of  one  ear  upon  opposite  organ — 
Physiological  interdependence — Pathological  correlation — Value  of 
Electrical  hyper.xsthesia  m  diagnosis — Prognosis — Duration  of  reflex 
symptoms — Nature  of  exciting  cause — Treatment — Early  adminis- 
tration of  bromides — Removal  of  exciting  cause — Anti>pasmodics — 
Opium  contraindicated — Tonic  treatment. 

CHAPTER    XLIV. 

Deaf-muiism 614-618 

Definition — Varieties — /Etiology.  CONGENITAL  Form.  Heredity 
— Consanguinity — Nationality — Social  condition — Defective  mental 
development — Specific  disease — Causes  operative  during  intra- 
uterine life.  .\c<ji'lRED  Form.  Traumatism — Infectious  diseases 
— Intracranial  disease — Middle-car  inflammation — .\denoid  vegeta- 
tions and  the  resultant  tympanic  condition — Cause  of  mutism  in 
acquired  form — Pathology — Congenital  malformation  of  conducting 
or  perceptive  mechanism — Obstructi%e  lesions  of  canal  or  tym- 
panum from  a  pathological  process — Pathological  conditions  in  the 
perceptive  mechanism — Secondary  atrophic  changes  — Symptoma- 
tology— Mutism  in  young  children — In  oliler  children  auditory  im- 
pairment fir^t  noticed — Diagnosis — Difflculties  in  ver)' young  chil- 
dren— Importance  of  complete  history — Imjiortance  of  thorough 
functional  examination  with  a  series  of  musical  tones — Prognosis — 
Congenital  cases — .Acquired  cases — Possible  errors — Treatment — 
Elimination  of  possible  causes  present — Remo  'al  of  adenoid  vege- 
tations— Internal  medication — Necessity  of  early  diagnosis — Early 
systematic  instruciion  in  cases  not  amenable  to  treatment. 

DISEASES  OF   THE  NOSE  AND  NASO-PHARYNX. 

Classification  of  pathological  conditions — Manner  in  which  various 
local  lesions  aff"ect  sense  of  hearing. 

CHAPTER    XLV. 

Hypertrophic  Rhinitis. — Deformities  of  the  Nasal  Sep- 
tum           620-625 

Hypertrophic  Rhinitis.  Nature  of  tissue  changes — Resultant 
conditions — Symptoms  referable  to  upper  air  passages — Aural  symp- 
toms—  Referable  to  mitldle  ear — Influence  upon  labyrinth — Relief 
of  labyrinthine  symptoms  from  intranasal  treatment — Sjieculum  ex- 
amination— Evidences  of  hypertrophy — Changes  following  the  use 
of  cocaine — Efi"ect  of  treatment — Technique  of  local  application — 
Surgical  treatment.  Deformities  of  the  Nasal  Septum.  Method 
of  removal  with  saw — Preparation  of  instruments — Dressing — Use 
of  galvano-cautery. 

CHAPTER    XLVI. 

Atrophic  Rhinitis 626-628 

Pathological  changes  in  membrane — Conditions  resulting  from  the 
atrophic  process — Insignificance  of  aural  symptoms — Relation  be- 


CONTENTS. 


XVll 


tween  aural  and  nasal  condiiions — Treatment — Irrigation — Precau-  ^''^^ 

lions  in  using  nasal  douche — Results  of  intranasal  treatment  upon 
the  aural  symptoms — Sprays — Local  stimulation. 

CHAPTER    XLVII. 
Adenoid  \'eget.\tio\.s 620-6^2 

Importance  of  condition — Diathetic  nature  of  affection — .Symptoms 
referable  to  upper  air  tract— .\ural  symptoms — Otalgia — Discharge 
—Impairment  of  function — "Inattention"  as  a  symptom — Condi- 
tion of  oro-phnrynx — Posterior  rhinoscopy — Recognition  by  anterior 
rhinoscopy— Digital  exploration— Technique  of  removal  with  for- 
ceps and  curette- Possible  Neipieht  to  o|)eration — Knlarged  faucial 
tonsils — Effect  upon  audition — Methods  of  removal  in  children  and 
adults. 

CHAPTER    .\L\TII. 
Naso-pharynce.\l  Catarrh 633-634 

Atrophic  nature  of  process — Symptoms  referable  to  vault  of  phar- 
ynx— Changes  in  ear  concomitant  rather  than  resultant — Aggrava- 
tion of  aural  condition  by  changes  in  naso-pharynx — Effect  upon 
audition  of  treatment  of  naso-pharynx — Topical  applications  in 
acute  conditions — Topical  applications  in  chronic  conditions. 


LIST   OF    ILLUSTRATIONS. 


COLORED   PLATES. 

PLATE 

L— The  Arterial  Supply  of  the  Conducting  Apparatus 
M— The  Venous  Supply  of  the  Conducting  Apparatus 
in. —The  Vascular  Supply  of  the  Cochlea 
IV  —The  Auditory  Nerve     .... 
V. — The  Memhrana  Tv.mpam  (i-6) 
VI.— The  Me.mhrana  Tv.mpaxi  (7-12) 
VII. — The  Mastoid  Operation 
VIII. — Operations  for  Intracranial  Co.mplications 


FACING 
PACB 

29 
30 

44 

45 
296 
296 

515 
527 


ILLISTRATIONS    IN     IHE    TEXT. 

FIGl'RR  PAGE 

1.  The  cartilaginous  framework  of  the  auricle          .....  4 

2.  The  auricle         ...........  5 

3.  The  cartilaginous  meatus   .........  6 

4.  The  incisures  of  Santorini 7 

5.  The  development  of  the  temporal  bum-       ......  8 

6.  Temporal  bone  of  infant     .........  9 

7.  The  adult  temporal  bone    .........  10 

8.  The  external  meatus  and  membrana  tympani  of  a  child  at  birth           .  10 

9.  External  meatus,  membrana  tympani,  and  middle  ear  from  a  child  five 

years  old     .         .         .         . 11 

10.  Sagittal  section  through  external  auditory  meatus,  membrana  tympani, 

and  middle  ear  of  an  adult .         .         .         .         .         .         .         .11 

11.  The  internal  tympanic  wall          ........  12 

12.  The  internal  tympanic  wall  and  the  vault  of  the  tympanum,  with  ossi- 

cles in  situ          ..........  14 

13.  The  ossicles  and  the  annulus  tympanicus 15 

14.  The  malleus,  incus,  and  stapes  in  various  positions     .         .         .         .16 

15.  The  tympanum  from  above         ........  18 

16.  Section  through  mastoid,  tympanum,  and  Eustachian  tube          .         .  19 

17.  Transverse  section  of  Eustachian  tube        ......  20 

18.  The  pockets  of  the  membrana  tympani       ......  24 

19.  The  maileo-incudal  articulation  covered  by  the  superior  malleo-incudal 

fold 24 

20.  The    nervs   of   the   conducting   mechanism   and   their  anastomotic 

branches     ......  32 


(xix) 


XX 


LIST   OF    ILLUSTRATIONS. 


ing  auricle 


FICURH 

21.  The  nerve  distribution  within  the  tympanum 

22.  The  bony  labyrinth    ..... 

23.  The  membranous  labyrinth 

24.  Vertical  section  of  the  membranous  cochlea 

25.  Pen  drawing  from  adult  specimen,  showing  result  of  draw 

upward  and  backward 

26.  Drawing  from  specimen  at  birth 

27.  Drawing  from  specimen  from  child  aged  five  years 

28.  Author's  portable  illuminating  apparatus 

29.  Hand  mirror       ..... 

30.  Reflecting  mirror  adapted  for  hand  or  head 

31.  Head  mirror  with  nasal  support 

32.  Head  mirror       ...... 

33.  Electric  lamp  worn  upon  the  forehead 

34.  Politzer's  hard-rubber  aural  speculum 

35.  Wilde's  aural  speculum 

36.  Gruber's  aural  speculum     .... 

37.  Toynbee's  aural  specula     .... 

38.  The  ocular  inspection  of  the  membrana  tympan 

39.  The  normal  membrana  tympani 

40.  Middle-ear  probe 

41.  Cotton  holder     .... 

42.  Siegle's  pneumatic  speculum 

43.  Auscultation  tube 

44.  Politzer's  air  bag 

45.  The  Eustachian  catheter    . 

46.  Introduction  of  the  Eustachian  catheter  (first  step) 

47.  Introduction  of  the  Eustachian  catheter  (second  step) 

48.  Introduction  of  the  Eustachian  catheter  (the  instrument  in  the  mouth 

of  the  tube) 

49.  Vertical  section   through  nasal  chambers  and   pharyngeal  vault 

adult 

50.  The  same  in  a  child  of  five  years 

51.  Section  through  nasal  passages  and  naso-pharyn.\  in  an  infant 

52.  Noyes's  Eustachian  catheter 

53.  Pomeroy's  faucial  catheter 

54.  Bosworth's  nasal  speculum 

55.  Bosworth's  tongue  depressor 

56.  Folding  tongue  depressor  .... 

57.  Tiirck's  tongue  depressor  .... 

58.  Rhinoscopic  mirror    ..... 

59.  Politzer's  acoumeter  ..... 

60.  Urbantschitsch's  electric  acoumeter  . 

61.  The  author's  tuning  fork    .... 

62.  The  author's  modification  of  the  Gallon  whistle 

63.  Blake's  tuning  fork     ..... 

64.  Hartmann's  series  of  tuning  forks 

65.  Anomalous  division  of  the  antihelix    . 

66.  Microtia 


PACE 

33 
34 

38 
42 


LIST   OF    ILLUSTRATIONS. 


XXI 


foralion  in  mem 


FICl'RB 

67.  Auricular  appendage 

68.  Fistula  congenita  auris 

69.  Polyotia   ..... 

70.  Aural  ice  bag  .... 

71.  Deformity  following  perichondritis 

72.  Otha-matoma    .... 

73.  Soft  fibroma  filling  the  concha. 

74.  Atheroma         .... 

75.  Sebaceous  tumor  of  the  lobule  . 

76.  Cystoma  of  auricle    . 

77.  Otitis  externa  acuta  circumscripta 

78.  Otitis  externa  acuta  of  deep  portion  of  meatus  . 

79.  Bacon's  scarificator  ...... 

80.  Author's  artificial  leech     ..... 
8j.  The  Leiter  coil  ...... 

82.  Hard-rubber  ear  syringe  ..... 

83.  Development  of  a  fungus  .... 

84.  Microscopic  characteristics  of  otomycosis 

85.  Otomycosis       ...... 

86.  Aspergillus  flavus     ...... 

87.  Appearance  in  infancy  due  to  escape  of  fluid  from  tympanum  through 

Kivinian  fissure  . 

88.  Acute  diffuse  external  otitis 

89.  Crust  on  supero-posterior  wall  of  canal  covering  per 

brana  tympani    ...... 

90.  Metliod  of  removing  cerumen  with  the  curette  . 

91.  Linear  rupture  of  the  membrana  tympani 

92.  Retraction  of  the  membrana  tympani 

93.  Author's  bougie  catheter  for  the  Eustachian  tube 

94.  Author's  middle-ear  vaporizer  .... 

95.  Moderate  retraction  of  membrana  tympani  ;  incudo 

lation  visible        ...... 

96.  Bulj^ing  of  the  posterior  seginent  of  the  membrana  tympani 

97.  Method  of  incising  the  membrana  tympani 

98.  Moderate  bulging  of  the  entire  membrana  tympani 

99.  Blake's  middle-ear  syringe        .... 
100.   Acute  purulent  otitis  media;  bulging  of  membrana  flaccida 
loi.   Acute  purulent  otitis  media;  fluid  confined   in   the  pockets  of  the 

membrane .... 
102.  Chronic  catarrhal  otitis  media ;   rotation  of  malleus  upon  its  long 

axis     ........... 

Chronic  catarrhal  otitis  media  ;  supernumerary  posterior  fold  . 
Chronic  catarrhal  otitis  media;  moderately  retracted  membrane 
Delstanche's  masseur        ........ 

106.  Chronic  purulent  otitis  media;  extensive  destruction  of  membrana 

vibrans        .......•■• 

107.  Chronic  purulent  otitis  media  ;  exuberant  granulations  in  tympanum 

108.  Chronic  purulent  otitis  media;  margin  of  perforation  partially  ad- 

herent        ......•••• 


stapedial  articu 


103 

104 
105 


395 


xxii  LIST   OF   ILLUSTRATIONS. 

FIGURE 

109.  Chronic  purulent  Otitis  media ;  perforation  in  membrana  flaccida 

1 10.  Chronic  purulent  otitis  media  ;  displacement  of  ossicles    . 

111.  Chronic  puruknt  otitis  media;  small  perforation  in  posterior  quad' 

rant     ........... 

112.  Removal  of  an  aural  polyp  with  the  snare         .... 

113.  Removal  of  an  aural  polyp  with  the  sharp  curette     . 

1 14.  Irrigation  of  the  tympanic  vault         ...... 

115.  Inspissated  secretion  covering  a  small  perforation  in  the  membrane 

116.  The  [)neumatic  mastoid    . 

117.  The  diploic  mastoid 

118.  Horizontal  section  through  mastoid,  showing  the  position  of  the  sig 

moid  groove         ......... 

1 19.  Section  through  mastoid,  showing  the  relative  position  of  the  latcra 

sinus  and  the  antrum  ........ 

120.  Section  through  mastoid,  showing  the  sinus  in  an  anomalous  posi- 

tion    ........... 

121.  Anomalous  development  of  the  temporal  ridge  ... 

122.  The  tympanic  vault  and  mastoid  antrum  at  birth      ... 

123.  Instruments  for  middle-ear  operations       ..... 

124.  Author's  head  and  shoulder  rest        ...... 

125.  Lance-shaped  myringotome      ....... 

126.  Method  of  incising  the  membrana  flaccida  for  depletion    . 

127.  Exploratory  myringotomy  ....... 

128.  Author's  scissors  for  middle-ear  operations        .... 

129.  Hartmann's  tenotome       ....... 

130.  Tenotomy  of  the  tensor  tympani       ...... 

131.  Tenotomy  of  the  tensor  tympnni       ...... 

132.  Tenotomy  of  the  tensor  tympani 

133.  Division  of  tympanic  adhesions         ...... 

134.  Division  of  adhesions  behind  the  stapes    ..... 

135.  Disarticulation  at  the  incudo-stapedial  joint       .... 

136.  Exposure  of  the  incudo-stapedial  joint 

137.  McKay's  ear  forceps 

138.  Incus  hook  in  position       ......•• 

139.  Author's  chisel  forceps      ...... 

140.  Incus  partially  destroyed  by  caries    ...... 

141.  Scalpel  for  incision  of  the  soft  parts  in  the  mastoid  operation    . 

142.  Thumb  forceps         .....••• 

143.  Scissors  cur\-ed  on  the  flat         ...••• 

144.  Sharp  retractor  ....■•••• 

145.  Periosteum  elevator  ....■••• 

146.  Hartmann's  periosteum  elevators      ....•• 

147.  Rongeur  forceps       .....-•■• 

148.  Sh.-irp  spoon     ......••■• 

149.  Schwartze's  chisels  ....••••• 

150.  The  vault  of  the  tympanum  as  seen  after  removal  of  the  outer  wall 

151.  The  topographical  relations    between  the  cranial  contents  and  th 

outer  surface  of  the  skull     ....... 

152.  Leucasmic  infiltration  of  the  cochlea  ..... 


si:cii()N  1. 


THE  AXATOMY  AXP   PIiysIOLOCY 
OF    THE   EAR. 


TIII^    ANAT().M\     AND 

pinsioLocA'  or  tiih   i:.\r. 


CMArTI-R    I. 

Till-:    ANATOMY    <>1"     IIIK    KAK. 

The  auditorv  apparatus,  tliroiij^li  llic  ajj^ciicv  of  which 
certain  forms  of  motion  are  interpreted  as  sound,  may  best 
be  c<jnsi(lered  as  consist ini;'  of  two  parts — a  conductiuij;'  mech- 
anism and  a  receptive  mechanism.  The  conducting  mech- 
anism collects  the  vibrations  of  the  sounding  body  and  trans- 
mits them  to  the  recei)tive  mechanism,  throui^h  which  this 
motion  is  recoj^nized  as  sound. 

This  division  of  the  subject  affords  a  inu(  h  clearer  view  of 
the  fimction  of  the  various  parts  concerned  in  audition,  in 
health  and  in  disease,  than  that  obtained  bv  adhering-  strictly 
to  the  anatomical  divisions  of  the  external,  middle  and  inter- 
nal ear. 

The  C(jnducting  api^aratus  includes  the  external  and  mid- 
dle ear.  The  middle  ear  is  simjjly  the  more  delicate  and 
complicated  portion  of  the  transmitting  mechanism,  and 
therefore  is  nK^re  carefully  protected  from  injury,  both  by  its 
situation  at  a  distance  from  the  external  surface  of  the  body 
and  by  the  presence  of  the  membrana  tympani.  It  is  probable 
that  the  function  of  this  structure  is  almost  entirely  protective, 
and  that  it  plays  but  an  imimportant  part  in  the  transmission 
of  sound  vibrations.  That  portion  of  the  conducting-  tract 
which  it  separates  from  the  outer  world  communicates  with 
the  surface  of  the  body  b}-  means  of  the  Eustachian  tube  :  it 
seems  wiser,  therefore,  to  consider  the  external  and  middle 
ear  and  Eustachian  tube  together,  rather  than  as  individually 
distinct,  since  they  perform  a  single  function. 

(3> 


THE    ANATOMY   AND    PHYSIOLOGY   OF    THE    EAR. 


The  second  pc^rtiini,  the  receptive  mechanism,  includes  not 
only  the  internal  ear.  or  labyrinth,  but,  in  addition,  the  trunk 
of  the  auditory  nerve,  its  central  and  cortical  nuclei  and  fibres 
of  association  and  projection.  The  labyrinth,  then,  represents 
but  a  small  portit)n  of  the  receptive  mechanism,  constituting 
the  specialized  end  organ  of  the  auditory  nerve,  through 
which  vibrations  in  the  labyrinthine  fluid  produce  specific 
impressions  upon  the  cerebrum.  It  can  be  seen  at  once  how 
much  more  comprehensive  the  range  of  aural  pathology  be- 
C(jmes  when  this  view  is  taken,  than  when  anatomical  divisions 
alone  are  followed. 

I.     TllK    CoXDl'CTINc;    Al'lAkATUS. 

Under  this  head  we  include  the  auricle  and  the  cartilag- 
inous meatus,  the  bony  external  auditory  meatus,  the  mem- 
brana  tvmpani.  the  tympanum,  and  the  Eustachian  tube. 

The  auricle  and  the  cartilaginous  meatus  together  form  an 
irregularly  funncl-sha|)ed  device  for  transmitting  aerial  vibra- 
tions to  the  dcejier  |)arts.  the  auricle  constituting  the  wide 
ptirtion  of  the  funnel,  the  cartilaginous  meatus  the  tubular 
{)()rti()n. 

The  Auricle. —  The  auricle  consists  of  a  thin  plate  ot  tibro- 
cartilage.   oval    in   outline,   attachetl    to   the  side  of  the  skull 

at  an  acute  angle 
with  the  median  an- 
tero-posterior  verti- 
cal plane  of  the  body. 
Its  posterior  surface 
is  convexand  smooth, 
while  the  concave 
anterior  surface  pre- 
sents certain  irreg- 
ularities which  merit 
special  description. 
The  unattached  bor- 
der of  this  oval  car- 
tilaginous    plate     is 

Fig.  I.— The  cirtil.-igiiioiis  fr.imework  of  the  .luricle.      folded  forward    upon 

(.Uter  I'oiitzer.)  jt^^^^lf  to  such  an  ex- 

tent that  the  free 
margin  appears  upon  the  anterior  or  external  surface,  form- 
ing the  helix.     Above,  the  helix   does  not  terminate  at  the 


THE    AURICLE. 


supcro-antcrior  attachment  of  the  auricle,  but  is  continued 
backward  and  sli<jfhtly  downward  from  this  point,  as  a  promi- 
nent rid<:^c,  the  crista  helicis.  which  forms  the  superior 
boundary  of  the  cartihii]^inous  meatus. 

At  the  base  of  the  crest  a  minute  spur  of  cartilage  ex- 
tends downward,  constituting  the  spina  helicis.  Followed  in 
the  opposite  direction,  the 
helix  is  seen  to  terminate 
in  an  elongated  cartilagi- 
nous process,  the  processus 
caudatus;  the  spine  of  the 
helix  and  the  caudate  pro- 
cess can  rarelv  be  recf)g- 
nizcd  on  the  living  subject, 
but  are  discernible  upon 
the  cadaver  after  carcfullv 
removing  the  integument 
covering  the  auiicle  (Fig. 
I). 

riugroDve  hi'tu-ath  the 
helix  is  called  the  fossa  of 
the  helix,  or  scaphoid    fossa. 


Helix 


Ami 
l.rh 


Immediatelv    in    front  of   this 


fossa  is  a  broad  convex  ridge  rumiing  j)aralltl  t«)  the  helix 
called  the  antihelix,  dividing  above  into  two  branches — the 
crura  helicis  or  the  crura  furcata.  These  crura  inclose  be- 
tween them  the  fossa  of  the  antihelix.  The  antihelix  termi- 
nates below  in  a  cartilaginous  [)romincnce — the  antitragus. 
Immediatelv  in  front  of  the  antihelix  and  extending  down- 
ward as  far  as  the  antitragus  is  a  deep  cavitv  called  the  con- 
cha: this  dej)ression  is  partiallv  divided  bv  the  spine  of  the 
helix  into  two  unequal  [)arts.  of  which  the  superior  is  the 
smaller  and  lies  between  the  spine  of  the  helix  and  the  ante- 
rior cms  of  the  antihelix.  while  the  larger  division  lies  in 
front  of  the  antihelix  and  above  the  antitragus.  As  already 
stated,  the  superior  margin  of  the  cartilaginous  meatus  is 
formed  bv  the  spine  of  the  helix  :  its  posterior  and  inferior 
margins  constitute  the  anterior  and  inferior  boundaries  of  the 
concha.  In  front  of  the  entrance  to  the  meatus,  slightly  cov- 
ering it  and  continuous  with  its  anterior  wall,  there  is  a 
prominent  cartilaginous  tubercle,  somewhat  pyramidal  in 
shape,  called  the  tragus.  This  is  separated  from  the  anti- 
tragus by  a  deep  broad  notch,  the  fissura  intcrtragica.     The 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 


tragus  is  not  completely  separated  from  the  antitragus  by  this 
fissure,  the  bases  of  the  two  processes  becoming  continuous  at 
the  junction  of  the  anterior  and  inferior  walls  of  the  cartilag- 
inous meatus.  Above,  the  tragus  is  completely  separated 
from  the  spine  and  crest  of  the  helix,  the  intervening  space 
being  filled  with  dense  connective  tissue. 

From  the  preceding  description,  it  will  be  seen  that  while 
the  contour  of  the  cartilaginous  margin  of  the  auricle  above, 
anteriorly  and  posteriorly,  is  fairly  regular,  its  infei-ior  margin 
from  the  processus  caudatus  of  the  helix  to  the  lissura  inter- 
tragica  presents  numerous  irregularities  of  outline.  These 
indentations  are  filled  up  by  a  mass  of  adipose  connective  tis- 
sue which,  extending  downward  for  a  variable  distance,  gives 
a  regular  outline  to  the  pinna.  To  this  process  the  name  of 
lobule  is  given.  The  walls  of  the  irregular,  funnel-shaped 
auricle,  therefore,  gradually  converge  to  form  the  cartilagi- 
nous meatus. 

The  Cartilaginous  Meatus. — The  lumen  of  this  canal  is 
oval  in  shaj)e  when  viewed  in   cross  section,  the  long  axis  of 

the  ellij)se  being  inclined  at  an 
angle  of  about  sixtv  degrees  to 
the  hori;^ontal  [)lanc.  The  in- 
ner extrcmitv  of  this  canal  is 
attached  by  means  of  firm 
bands  of  connective  tissue  to 
the  margin  of  the  bony  meatus, 
rhe  cartilaginous  framework 
of  the  canal  is  wanting  above 
and  posteriorly,  this  deficiency 
becoming  greater  as  the  canal 
extends  inward,  until  at  its  ter- 
mination the  inferior  wall  only 
is  cartilaginous,  being  pro- 
longed for  a  short  distance 
along  the  floor  of  the  bony 
meatus  as  a  tongue-shaped  cartilaginous  process,  known  as 
the  processus  triangularis*  (Fig.  3). 

The  wall  of  the  canal  is  completed  bv  firm  connective  tis- 
sue, which  fills  up  the  hiatus  in  its  cartilaginous  portion.  This 
fibrous  tissue  is  continuous  with  the  periosteum  of  the  corre- 


T 


Fig.  3. — The  cartilaginous  meatus. 
(Politzer).  c,  Processus  triangu- 
laris ;   i,  i,  Incisures  of  Santoiini. 


Politzer,  Zergliederung  des  menschlichen  Gehororgans,  1889,  p.  57. 


Till-:  EXIKKNAL  MEATUS. 


sponding  portion  of  tlie  bony  canal.  The  anterior  wall  of  the 
cartilaginous  meatus  presents  two  vertical  fissures  (Figs.  3 
and  4)  which  pass  completely  through  its  substance.  The 
spaces  thus  left  are  filled  with  connective  tissue,  with  an 
occasional  admixture  of  striped  muscular  fibres.  These  fis- 
sures are  called  the  incisures  of  Santorini.  The  more  extensive 
of  the  two  is  situated  at  the  base  of  the  tragus;  the  second  is 
farther  inward,  while  a  third  is  occasionally  nut  with  bcxond 
this.  These  fissures  ren- 
der the  cartilaginous 
meatus  more  freely  mov- 
able, and  arc  important 
clinicallv,  for  through 
them  deej)  abscesses  of 
the  parotid  gland,  dis- 
charging spontaneous!  V. 
rupture  into  the  canal 
on  account  ol  the  weak- 
ness of  tiic  walls  at  this 
])oint.  I'rom  a  surgical 
standpoint  these  dehis- 
cences are  imj>f)rtant. 
since  thev  enable  us  to 
turn  the  auricle  and  fibrocartilaginous  canal  forward  on  the 
cheek,  after  sejK'iration  of  the  j)osterior.  inferior,  and  sui)erior 
attachments. 

The  Bony  Canal. — In  order  properly  to  understand  the 
osseous  meatus,  it  will  be  necessary  to  consider  somewhat  in 
detail  the  development  of  the  temporal  b(Mie.  This  portion 
of  the  skull  develops  from  four  centers:  the  squamous,  the 
petro-mastoid,  the  audit(jry  or  tymjianic.  and  the  stylomas- 
toid. This  last  center  of  ossification  does  not  concern  us,  but 
the  other  three  are  of  importance,  as  they  are  all  integral  parts 
of  the  auditorv  aj)paratus.  and.  with  the  exception  (jf  the  pe- 
trous portion,  all  enter  into  the  formation  of  the  external 
meatus.  The  manner  in  which  these  various  portion  unite 
to  form  the  temporal  bone  is  shown  in  Fig.  5.  which  is  some- 
what diagrammatic. 

The  osseous  meatus  does  not  exist  at  birth,  its  {)lace  being 
supplied  bv  a  canal  of  fibrous  tissue.  Reference  to  Figs.  8, 
9,  and  10,  drawn  from  specimens  prepared  by  the  author, 
renders  this  clear.     At  its  inner  extremitv  this  terminates  in 


li( 


4— a. 


1,  '1  lie  iiKi-<ures  i>f  ^anlorini. 
( I'rhanlschitsch.) 


8    THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

the  auditory  process  or  the  tympanic  ring.  The  auditory 
process  (Figs.  5  [2]  and  13  [III])  consist  of  a  thin  osseous  strip 
bent  in  the  form  of  an  oval,  the  curvilinear  outline  being 
wanting:  for  about  an  eijjhth  of  its  circumference  at  the  broader 


Fig.  5. — The  development  of  the  temporal  bone,  i,  The  squamous  portion  ;  2, 
The  tympanic  ring  ;  3,  The  petro-mastoid  portion.  The  upper  figure  illustrates 
the  union  of  the  three  portions.     (Modified  from  (Iray.) 


pole.  The  concave  margin  of  this  bonv  ring  is  grooved  for 
the  insertion  of  the  mcnibrana  tvmpani,  and  is  named  the 
sulcus  tympanicus,  while  the  ring  itself  is  called  the  annulus 
tympanicus.  The  free  extremity  of  the  posterior  limb  of  the 
annulus  is  called  the  spina  tvmpanica  posterior  or  spina  tvm- 
panica  minor.  Just  below  the  extremity  of  the  anterior  limb 
a  bony  spine  projects  backward,  the  spina  tympanica  major. 
The  spina  tympanica  anterior  is  directed  forward,  and  con- 
sists of  a  small  bony  tubercle  lying  just  beneath  the  larger 
tympanic  spine. 


Tin:  noNY  mkatus.  q 

The  scjuamnus  jiortion  ni  the  temporal  bone  develops 
from  a  sinij^le  center.  Karly  in  Icrlal  life  it  consists  of  a  flat 
osseous  scale,  presenlinjj  a  ridj^^e  upon  its  outer  surface, 
which  afterward  becomes  the  zygomatic  process.  Below  the 
root  of  this  j)rocess  is  a  shallow  excavation,  the  aflenoid  fossa. 
!5ehind  this  depression  the  bonv  plate  divides  into  two  la- 
mella;, the  inner  of  which  is  directetl  almost  horizontally 
inward  and  forms  subseciuentlv  the  roof  of  the  tympanum 
and  of  the  mastoid  antrum.  The  external  lamella  passes 
downward  and  somewhat  inward  :\\n\  exhibits  a  deep 
notch  upon  its  inferior  border.  The  annulus  tvmpanicus 
joins  the  external  plate  of  the  scjuama  by  the  union  of  the 
free  extremities  of  its  anterior  and  posterior  limbs  to  the 
corresponding  anj^Ies  of  the  n«»fih  above  described.  Ilie 
curvilinear  outline  of  the  rinj^  i- 
ciMUjtleted  by  the  notched  inferior 
border  of  the  external  plate  of  iIk 
squamous  portion  of  the  temjioral 
bone.  riiis  is  shown  in  I'ij^.  t». 
The  circlet  thus  completed  jjives 
attachment  to  the  inner  extremity 
of  the  fibrous  canal,  which  occupies 
the  position  of  the  future  bony 
meatus.         As     development     pro-  "^X:*-^     ^ 

L,^resses.  the  fibrous  canal  is  replaced  ^^  '^  ' 

I  ^.  Ti  ,  I'lr,.  6. — Temporal  Ixine  of  in- 

by      osseous     tissue.        The     annulus  fam.  nalur.Vl  sire.    (.Authors 

tvmpanicus     is     converted     into    a  collection 

l)(»nv  ijroovc  bv  ossification  out- 
ward, and.  as  will  be  seen  by  ct)nsultinjj  Fij^s.  S.  9,  and  10, 
the  |»roccss  eflects  simply  the  separation  of  the  superior 
and  inferior  walls,  which  at  birth  are  in  contact.  This  putter 
forms  the  atiteri«)r.  interior,  and  posterior  walls  of  the  bony 
meatus,  the  suj>erior  wall  beinj;  formed  by  that  portion  of 
the  temporal  bone  which  completes  the  osseous  outline  of 
the  .iiinulus  tvmpanicus. 

In  the  atlult  temporal  bone  (Fig^.  7)  the  deep  groove  formed 
by  the  outward  growth  of  the  annulus  tympanicus  is  called 
the  auditory  process.  It  is  separated  in  front  from  the  squa- 
mous portion  of  the  temporal  bone  by  a  narrow  fissure  called 
the  Glaserian  fissure  ;  posteriorly  the  auditory  j)rocess  enters 
into  the  formation  of  the  mastoid  squamous  suture,  its  postero- 
superior  termination  constituting  the  spinum  supra-meatum. 


lO 


THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 


The  external  plate  of  the  squama,  which  completes  the  out- 
line of  the  bony  meatus,  during  development  grows  almost 


Fk;.  7. —  The  adult  temporal  bone,  natural 
size.     (Author's  collection.) 


directly  outward  in  a  horizontal  direction,  and  nearly  at  right 
angles  to  that  portion  of  the  temporal  bone  lying  above  the 

zygomatic  process.  As  previously 
stated,  the  fibrous  tissue  which  oc- 
cupies the  place  of  the  bonv  meatus 
at  birth  is  gradually  replaced  by 
/ m^^^^^^  bone,  and  this  part  of  the  meatus, 

y  i^^^^^^^L  which    at    first    was    movable,    be- 

comes bony  and   rigid.     As  a  re- 
sult, the  angle  between  the   mem- 
hrana    tympani    and    the    superior 
I    -^-^    *  \  ^^^H       ^^'''^   '*^  ^^  canal  becomes  appar- 
/  ^^jJW  I y     ^ij^B       entlv   more  acute  as  development 
'  advances.     The  actual  angle  of  in- 

clination of  the  membrane  with  the 
horizontal  plane  probably  does  not 
change  to  anv  degree  after  birth. 
The  line  of  demarcation  between 
Fig.  8. — The  external  meatus  and     it   and    the   Superior  wall   is   morc 

membrana  tympani  of  a  child  at  .,  ,  ^    •  11  1  -ij 

birth,  natural  size.  The  meatus     easily  made  out  m  oldcr  children 

has  been  split,  and  the  supeiior      ^^^^      adultS,      OU      aCCOUUt      of      the 
and    inferior    walls   have    been  1  •        1 

held  apart.  (Author's  specimen.)     change  taking  place  in  the  meatus. 


THE    HONY    MKATUS. 


I  1 


At  birth  the  su{»L"ri()r  and  inferior  walls  arc  in  CDiitact  and 
must  be  separated  in  order  to  inspect  the  membrana  tympani. 
as  the  specimen  from  which  Fi^^.  8  was  drawn  shows.  In 
this  specimen  the  anterior  wall  of  the  canal  was  cut  throuj^h. 
Irom  just  in  front  of  the  tragus  to  the  membrana  tvnij)ani. 
and  the  walls  separated  so  that  the  parts  could  be  seen  and 
drawn. 

When  we  compare  this  drawing  with  Figs.  9  and  10,  repre- 
senting the  same  region  in  childhood  and  adult  life,  we  see 
at  once  that  the  formation  of  the  bonv  canal  may  be  said  to 
have  eflected  this  separation  and  made  it  j>ermanent.  simj>lv 
by  the  deposit  of  bony  tissue,  rendering  the  hbrous  tube  rigid. 


FlO.  g. — External  mc.itU'-,  mfniiir:iii.i  tym- 
pani, anil  middle  car  from  a  child  five 
years  of  age,  natural  size.  (Aiulvr''; 
specimen.) 


Ik,.  H). — ^ayittal  section  through  ex- 
ternal auditory  meatus,  membrana 
tvmpani,  and  middle  ear  of  an  adult, 
natural  size.     (Authoi's  collection.) 


The  third  portion  of  the  temporal  b(jne.  the  petro-mastoid 
part,  consists  of  an  oblique  triangular  osseous  pyramid,  the 
apc.x  of  which  is  directed  forward  and  inward,  while  its  base 
fills  up  the  gap  between  the  free  margin  of  the  squamous 
plate  of  the  temporal  bone  and  the  posterior  crus  of  the 
annulus  tymjianicus.  at  the  same  time  extending  forward,  so 
that  the  anterior  portion  of  this  surface  lies  opposite  the  tym- 
panic ring. 

The  line  of  union  of  the  mastoid  portion  to  the  external 
squamous  plate  is  the  mastoid  squamous  suture.  Looking  at 
the  cranial  surface,  we  find  that  the  petrous  portion  unites 


12    THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

with  the  inner  plate  of   the  squama,  forming  the   petro-squa- 
mous  suture. 

It  is  clear  from  the  foregoing  description  that  the  base  of 
the  pyramid  is  made  up  of  the  outer  surface  of  the  mastoid 
and  of  that  portion  of  the  petrous  bone  lying  below  the  petro- 
squamous suture  and  opposite  the  tympanic  ring.  This  last 
region  corresponds  to  the  inner  wall  of  the  tympanic  cavity, 
or  the  fundus  of  the  external  auditory  meatus,  the  membrana 
tympani  having  been  removed. 

The  Tympanic  Cavity. — The  tympanic  cavity  is  a  bony 
chamber  the  inner  wall  of  which  is  formed  by  the  external 
surface  of  the  petrous  portion  of  the  temporal  bone.  This 
wall  (Fig.    ii)  presents  for  inspection  a   rounded   eminence, 

called  the  promontory,  covering 
the  first  turn  of  the  cochlea.  Be- 
hind, and  somewhat  beneath  the 
promontory,  there  is  a  niche  called 
the  niche  of  the  round  window, 
into  which  the  fenestra  rotunda 
opens.  This  niche  looks  almost 
directly  backward,  and  even  when 
the  parts  are  most  favorably  dis- 
posed for  inspection,  but  a  very 

'''^vLI^,A,uhi°rs;;«ir„T'''  li!"!"-''  •■'••'"-  <''  «.he  depression  is 

visible.  Above,  in  the  upper  and 
posterior  portion  of  the  inner  wall,  is  an  oval  fossa,  the  pelvis 
ovalis,  at  the  bottom  of  which  is  the  oval  window.  In  F"ig. 
1 1  the  stapes  is  in  position,  and  fills  the  pelvis  ovalis.  The 
posterior  wall  of  the  pelvis  ovalis  is  abrupt,  while  its  anterior 
wall  slopes  gradually  forward  until  it  merges  into  the  sur- 
face of  the  promontory.  The  inferior  wall  is  longer  and 
more  precipitous  that  the  superior  wall.  The  lumen  of  the 
fenestra  ovalis  looks  outward  and  downward.  At  birth  the 
pelvis  ovalis  is  separated  from  the  niche  of  the  round  win- 
dow by  a  deep  fossa,  the  sinus  tvmpanicus  (seen  in  Fig.  6), 
which  usually  disappears  completelv  in  adult  life.  Above 
the  oval  window  there  is  a  distinct  bonv  arch  formed  bv  the 
encroachment  of  the  outer  wall  of  the  aqueductus  Fallopii 
upon  the  tympanic  cavitv.  The  facial  nerve  passes  through 
this  canal.  Directly  above  this  bonv  ridge  there  is  another 
and  smaller  bonv  crest,  caused  bv  the  projection  of  the  hori- 
zontal  semicircular    canal    outward    into    the    cavit\-    of    the 


THK    TYMPANIC    CAVirV.  1  ^ 

middle  ear.  The  outer  wall  of  the  aqueductiis  Fallopii  is 
occasionally  incomplete,  the  facial  nerve  bcini;  then  exposed 
in  its  passage  through  the  tympanum.  Behind  the  pelvis 
ovalis,  at  the  juncture  of  the  inner  and  posterior  walls  of  the 
tympanum,  there  is  a  small  bony  pyramid,  through  the  apex 
ol  which  the  tendon  of  the  stapedius  muscle  passes.  The 
plane  of  the  inner  wall  of  the  tympanic  cavity  lies  more 
nearly  in  the  median  antcro-posterior  vertical  plane  of  the 
body  than  docs  that  of  the  tympanic  ring;  hence  the  tvm- 
panic  cavity  is  broader  above  and  posteriorly,  than  below 
and  anteriorly.  In  front  of  the  promontorv  the  inner  wall  is 
smooth  and  gradually  merges  into  the  tvmpanic  o])ening  of 
the  luistachian  tube. 

The  anterior  wall  of  the  tympanum  presents  at  about  its 
centre,  the  tympanic  orifice  of  the  Eustachian  canal.  Above 
this,  and  sej)aratetl  from  it  bv  a  thin  bony  |)late,  the  ])roces- 
sus  cochleariformis.  is  the  canal  for  the  tendon  of  the  tensor 
t\  inpani  muscle.  The  anterior  wall  is  separated  from  the  in- 
ternal carotid  aiti'iv  as  it  jtasses  through  the  carotid  canal 
1)\  a  thin.  Ixtia  plati-.  Thi-  osseous  lloitr  of  the  cavit\-  lies  at 
a  considerable  distance  below  the  lower  margin  of  the  t\  in- 
])anic  ring.  It  is  sometimes  formed  of  fairly  compact  bone, 
but  tjuitc  frcquenth  it  is  cancellous;  it  is  in  relation  with  the 
jugular  fossa,  which  lotlges  the  bulb  of  the  internal  jugular 
\cin,  and  may  present  dehiscences,  exposing  the  bulb  to  trau- 
matism by  instruments  introduced  into  the  meatus. 

The  i)osteri<)r  wall  presents,  at  its  junction  with  the  inter- 
nal wall,  the  pvramid,  through  the  apex  of  which  the  tendon 
of  the  stapedius  muscle  passes.  The  opening  into  the  mastoid 
antrum  lies  directly  above  this  process.  The  external  wall  of 
the  tvnipanum  is  fcMined  chiefly  by  the  membrana  tympani 
(a  structure  which  will  be  described  presently),  by  the  inner 
surface  of  the  tympanic  ring,  and  above  by  the  inner  margin 
of  the  external  plate  of  the  scjuama  and  by  the  angle  formed 
bv  the  separation  of  the  inner  and  outer  plates.  It  becomes 
evident,  therefore,  that  the  tympanic  cavity  is  prolonged  up- 
ward for  a  C(onsiderablc  distance  above  the  plane  of  the  supe- 
rior wall  of  the  meatus.  This  portion  of  the  cavity  is  the 
epitympanic  space  or  recess,  or  the  vault  of  the  tympanum. 
The  portion  Iving  below  this  plane  is  called  the  atrium. 

The  Vault  of  the  Tyvipanuni  (Fig.  12). — The  epitympanic 
space  is  somewhat  pvramidal  in  shape,  the  apex  lying  at  the 


14 


THE    ANATOMY    AND    1'HVS10I.0(;Y    OP^    TllK    KAR. 


Fig  12. — The  internal  tympanic  wall 
and  the  vault  of  the  tympanum, 
with  the  ossicles  in  position.  (.Au- 
thor's collection.) 


angle  between  the  two  plates  of  the  squanui.  These  plates, 
with  the  adjoining  portions  of  the  petrous  bone  and  the  petro- 
squamous suture,  complete  two 
osseous  faces  of  the  pyramid; 
the  remaining  surface  and  the 
base  are  partly  wanting,  being 
represented  bv  the  openings 
leading  into  the  mastoid  antrum 
posteriorly,  and  into  the  tym- 
panic cayity  below.  When  the 
jiarts  are  in  their  normal  posi- 
tion this  lower  surface  is  par- 
tially completed  by  theossicula, 
their  ligaments,  and  the  redu- 
plications of  the  mucous  lining 
of  the  tympaniun.  which  shut  off  the  upper  portion  of  the 
cayity  more  or  less  perfectly  from  the  lower  part. 

The  Ossicles  (F'igs.  13  and  14). —  The  ossicular  chain  is 
lodged  within  the  tympanum,  and  scryes  to  transmit  and 
modify  sound  vibrations.  It  constitutes,  in  reality,  a  lever 
through  which  the  impulses  transmitted  to  the  labyrinthine 
fluid  are  increased  in  intensity,  but  diminished  in  amplitude. 

The  ossicles  are  three  in  number:  the  malleus,  incus,  and 
stapes.  According  to  Rathkc"  and  Urbantschitsch.+  the 
malleus  and  incus  are  developed  from  one  nucleus,  and  sub- 
sequently become  separate  bones,  intimately  connected  at 
their  articular  surfaces,  while  the  stapes  develops  from  a  dis- 
tinct centre  of  its  own. 

Gradenigo :{;  believes  that  the  foot  plate  of  the  stapes 
springs  from  the  capsule  of  the  labyrinth,  while  the  remain- 
der develops  from  the  second  visceral  arch,  the  two  portions 
subsequently  uniting. 

The  Malleus. — The  malleus  is  the  largest  ossicle  of  the 
series,  and  consists  of  a  head  and  shaft  joined  to  each  other  at 
an  obtuse  angle  by  a  constricted  portion  called  the  neck.  The 
shaft  or  long  process  is  prismatic  on  cross  section,  and  tapers 
gradually  from  just  below  the  neck  of  the  ossicle  to  the  tip, 
which  is  sometimes  bent  slisrhtlv  forward  in  the  form  of  a  hook. 


*  Kiemenapp.  und  Zungenb.,  1832,  p.  122. 
t  Lehrb.  der  Ohrenheilk.,  Wien,  1890,  p.  229. 
X  Med.  Jahrbuch,  Wien,  1887. 


THi:    OSSICLKS.  15 

\t  thf  junction  of  the  shaft  w  itii  tlu-  neck  there  is  a  proniincnt 
l)t)nv  tuliercle  called  tlie  short  jtrocess  of  the  malleus,  which 
is  directed  forward  and  outward.  The  j)risniatic  shaft  i»re- 
sents  an  external  border  for  attachment  to  the  membrana 
tvmpani,  an  internal  border  directed  toward  the  labyrinthine 
wall,  and  somewhat  broad  anterior  and  [)ostcrior  surfaces.  It 
is  eviflent  that  anv  rotation  of  the  malleus  upon  the  loiii^  axis 


111-.    i.V — ;;...■-,,,-. ,,.     ,.-,,  i..|.., ,,,,>.  .      I.   <  •^^icular  cliain  <>l   Icfi  car. 

1,  Malleus  ;  2.  Incus  ;   3,  Stapes.      II.  «  »s>.iculus  chain  of  right  ear.      I,  Malleus  ; 

2,  I'rocc-sus  foiianus  ;  3,  Manubrium  ;  4,  l-ong  process  of  incus  ;  5,  Short  pnicess 
of  incus  ;  6,  Stapes.  Ill,  .\nnulus  tympanicus.  i.  Anterior  tubercle  ;  2,  Pos- 
terior tubercle,     (kiidinger:    n!ake'>  translation.) 

(^f  the  manubiiiim  will  alter  the  aj)j>arent  breadth  of  the  shaft 
as  viewed  throuirh  the  meatus,  accordin"-  as  the  decree  of 
rotation  brinies  the  brf)ad  anterior  or  posterior  surface  into 
view,  or  the  sharp  ed^e  which  marks  the  junction  of  these 
surfaces  with   the  antericjr  border.     Springing  from  the  an- 


l6        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

terior  surface  just  below  the  short  process  is  a  long,  delicate, 
bony  spicule,  the  processus  folianus  or  gracilis,  which  lies  in 
the  Glaserian  fissure,  and  in  adult  life  is  frequently  imbedded 
in  the  fibres  of  the  anterior  ligament.  The  external  surface 
of  the  neck  of  the  malleus  is  roughened  for  the  attachment  of 
the  external  lis-ament.     The  anterior  surface  of  the  neck  and 


Fig.   14. —  The  malleus,  incus,  and  stapes  in  various  positions.     (Rudinger  :   Blake's 

translation.) 

the  adjoining  portion  of  the  head  are  deeplv  grooved  for  the 
insertion  of  the  anterior  ligament.  The  head  is  irregularly 
spherical  in  shape,  the  spherical  contour  being  encroached 
upon  posteriorly  by  the  saddle-shaped  surface  for  articulation 
with  the  incus,  while  anteriorly  there  is  a  groove  for  the  at- 
tachment of  the  anterior  ligament. 


THE   OSSICLKS.  1 7 

The  Incus. — The  central  ossicle  of  the  chain  consists  of  a 
body  and  two  processes.  The  short  or  horizontal  process — a 
continuation  of  the  body — is  conical  in  shape  and  extends 
backward,  its  tip  resting  in  a  little  pit  or  fossa  in  the  posterior 
tympanic  wall,  just  below  the  entrance  to  the  mastoid  antrum. 
This  depression  is  called  the  sella  incudis.  The  body  of  the 
bone  is  flattened  from  before  backward,  the  vertical  diameter 
being  about  double  the  transverse.  The  anterior  surface, 
forming  the  base  of  the  cone,  is  saddle-shaped  for  articulatit)n 
with  the  malleus.  The  long  or  descending  ramus  t)f  the  incus 
is  a  long,  tapering  bony  shaft,  extending  downward  from  the 
antero-inferior  angle  (A  the  body  ;  its  lower  extremity  is  bent 
inward  so  that  the  tip  of  the  process  is  directed  toward  the 
internal  tympanic  wall.  This  free  extremity  is  called  the  len- 
ticular j)rocess.  and  articulates  with  the  head  of  the  stapes. 
The  lenticular  process  in  foetal  life  is  represented  by  a  sepa- 
rate bone,  the  os  orbiculare. 

The  Sfi7/>es. — The  innermost  ossicle  of  the  series  brings  the 
conducting  mechanism  into  immediate  relation  with  the  re- 
ceptive apparatus.  As  the  name  implies,  it  is  stirrup-shaped, 
and  consists  of  a  small  rounded  head  the  external  face  of 
which  is  hollowed  out  for  articulation  with  the  lenticular  pro- 
cess of  the  incus ;  below  the  head  is  a  constricted  portion 
called  the  neck,  from  which  the  crura  diverge.  The  posterior 
crus  is  the  longer  and  more  curved.  The  crura  terminate  in 
an  oval  or  kidney-shaped  plate  of  bone,  the  foot-plate  of  the 
stapes,  which  closes  the  oval  window.  The  entire  stapes  lies 
almost  wholly  within  the  pelvis  ovalis,  hence  when  the  mem- 
brana  tympani  is  wanting  it  is  well  protected  from  traumatism 
from  instruments  introduced  through  the  canal.  The  stapes 
lies  obliquely  in  the  oval  niche,  being  nearer  to  the  inferior 
and  posterior  walls  of  the  fossa  than  to  the  anterior  and  supe- 
rior. Since  the  posterior  wall  of  the  niche  is  almost  vertical, 
the  corresponding  stapedial  crus  lies  close  to  it,  and  adhesions 
between  this  wall  and  the  posterior  limb  of  the  ossicle  are  of 
frequent  occurrence. 

The  ossicular  chain  is  suspended  in  the  tympanic  cavity 
by  a  series  of  ligaments  which  bind  the  individual  members 
of  the  chain  to  each  other  and  to  the  walls  of  the  tympanum. 

Ligaments  of  the  Malleus  (Fig.   15). — These  are  four  in 
number  :  the  anterior,  external,  posterior,  and  superior  or  sus- 
pensory ligament. 
3 


1 8        THE    ANATOMY    AND    PHYSIOLOGY   OF    THE    EAR. 

The  anterior  ligament  is  the  strongest  of  these.  It  arises 
from  the  spina  tympanica  major  and  from  the  walls  of  the 
Glaserian  fissure,  some  of  the  fibers  traversing  the  length  of 
the  fissure  and  taking  their  origin  from  the  spine  of  the  sphe- 


Mastoid  .,.      ,.^  External  ligament, 

antrum. 


.Anterior  ligament. 


Stapes. 

Tendon  of  tcii- 
scir  tympani. 

Fig.  15. —  The  tympanum  from  above.      (Author's  specimen  ) 

noid.  From  this  extensive  origin  they  pass  outward,  upward, 
and  backward,  and  are  inserted  into  the  anterior  surface  of 
the  neck  of  the  malleus  and  into  the  depression  found  on  the 
anterior  surface  of  the  head.  They  inclose  the  processus 
folianus  of  the  malleus. 

The  external  ligament  is  somewhat  fan-shaped.  It  springs 
from  the  external  roughened  surface  of  the  neck  of  the  ossicle, 
from  which  point  the  fibers  diverge  to  be  inserted  into  the 
free  margin  of  the  inner  extremity  of  the  superior  wall  of  that 
portion  of  the  bonv  meatus  formed  by  the  external  plate  of  the 
squama.  The  posterior  fibres,  according  to  Helmholtz,  form 
a  distinct  band  called  the  posterior  ligament  of  the  malleus.* 

This  portion  of  the  external  ligament,  together  with  the 
anterior  ligament,  forms  the  axis  band  of  the  hammer,  since 
the  axis  of  rotation  of  the  ossicle  is  approximately  a  line  drawn 
through  the  attachment  of  these  two  ligamentous  structures. 

Tlie  superior  ligament  is  a  delicately  rounded  band  of 
fibrous  tissue  running  from  the  tegmen  tympani  downward 
to  the  head  of  the  malleus. 

The  Ligaments  of  the  Incus. — The  incus  is  bound  to  the 
tympanic  wall  by  a  single  fibrous  band,  the  posterior  liga- 

*  The  Mechanism  of  the  Ossicles.     Translated  by  Buck  and  Smith,  New  York, 

1873. 


THi:    IN  rKAlYMPANIC    LIGAMENTS. 


•9 


mciit,  which  extends  from  the  lateral  aspects  of  the  short 
process  near  its  extremity  to  the  posterior  wall  of  the  tym- 
panum. At  its  oriiyin  it  is  dense  in  structure,  owin^  to  tlie 
somewhat  limited  area  from  which  it  arises.  From  this  point 
the  fibres  diverge  rapidly  and  divide  into  two  bundles  to  be 
inserted  into  a  broad  area  on  the  {)osterior  wall  of  the  tvm- 
panimi.  On  account  of  this  broad  insertion  it  is  sometimes 
called  the  fan-shaped  ligament  of  the  incus.  The  inferior  sur- 
face of  the  short  process  lies  in  a  shallow  depression  in  the 
tvmpanic  wall  called  the  sella  incudis.  the  opposing  surfaces 
being  covered  with  cartilage. 

The  Ligaments  of  the  Stapes. — The  foot  plate  of  the 
stapes  is  contined  in  the  oval  window  by  the  stapedio-ves- 
tibular  or  annular  ligament.  The  margins  and  vestibular  sur- 
face of  the  foot  plate  and  the  periphery  of  the  oval  window 
are  covered  with  hyaline  cartilage,  the  annular  ligament  de- 
veloping from  the  perichondrium. 

Interossicular  Ligaments. — The  malleus  .•lul  incus  are 
bound  titg(  thir  by  a  lo(»se  capsular  ligament,  the  articular 
surfaces  of  the  ossicles  bf'ing  covered  with  cartilage.  The 
incu(lo-'«tap(.(li;iI  artiiulation  is  similar  in  character. 

The  Eustachian  Tube. —  Having  traced  the  bony  and  car- 
tilaginous framework  of  the   conducting  mechanism  inward 


'V^ 


V 


w 


»-rfi^ 


•op 


Fin.  i6. — Seciioii  liirooj^li  iaaj>ioui.  tympanum,  and  Eustachian  tube,  (rolilzer.) 
W,  W,  Mastoid  cells;  mt,  Mcmbrana  tympani  ;  an,  Antrum  ;  n.  Vault  of  tym- 
panum ;  it.  Isthmus  of  tube  ;  te.  Eustachian  tube  ;  op,  Pharyngeal  orifice  of 
tube. 


to  the  point  where  it  joins  the  receptive  portion  of  the  audito- 
ry apparatus  at  the  oval  window,  we  have  next  to  consider 
the  characteristics  of  that  passage  by  means  of  which  certain 
delicate  parts  of   this  system  can  be  protected  by  a  fibrous 


20        THE    ANATOMY    AND    PHYSIOLOCxY    OF    THE    EAR. 

covering-  without  interferinof  with  the  transmission  of  sound 
waves.  By  means  of  the  canal  now  to  be  described  an  equal 
atmospheric  pressure  is  maintained  upon  either  side  of  this 
protecting  septum.  This  passage  is  the  Eustachian  tube.  It 
is  made  up  of  two  portions — the  tympanic  or  bony,  and  the 
pharyngeal  or  cartilaginous  portion — their  point  of  junction 
being  called  the  isthmus  of  the  tube.  The  osseous  segment 
is  about  half  an  inch  in  length,  and,  extending  from  a 
somewhat  wide  orifice  just  above  the  middle  of  the  internal 
wall  of  the  tympanum,  narrows  quickly  as  it  passes  down- 
w^ard,  forward,  and  inward  through  the  substance  of  the  pe- 
trous portion  of  the  temporal  bone,  until  at  the  isthmus  its 
diameter  varies  from  one  twenty-fifth  to  one  twelfth  of  an 
inch.  The  canal  is  irregularly  triangular  in  shape,  the  verti- 
cal diameter  being  double  the  transverse.  This  osseous  tube 
is  joined  at  the  isthmus  to  the  cartilaginous  portion  by  fibrous 
tissue,  the  parts  uniting  at  an  obtuse  angle,  the  opening  of 
which  is  directed  downward  and  forward.  The  pharyngeal 
portion  measures  about  an  inch  in  length,  and  at  the  isthmus 
its  lumen  corresponds  to  that  of  the  osseous  channel.  As  it 
extends  downward  into  the  pharynx,  however,  it  grows  wider, 
and  at  the  pharyngeal  orihcc  measures  from  one  eighth  to 
one  Hfth  of  an  inch  in  diameter,  the  vertical  diameter  being 
greater  than  the  transverse.  This  portion  of  the  canal  is 
fibrocartilaginous.  The  posterior  wall 
is  formed  by  a  plate  of  cartilage,  the 
upper  border  of  which  is  bent  first 
,  _     ,^  forward   and   then  downward,  so   that 

a  transverse  section  would  be  hook- 
shaped  (see  Fig.  17).  The  space  in- 
closed by  the  bending  forward  of  the 
cartilage  forms  the  superior  portion  of 
the  lumen  of  the  tube,  the  interval  be- 
tween the  free  margin  of  the  angular 
portion  and  the  lower  border  of  the 
cartilaginous  plate  being  filled  with 
Fig.  17.— Transverse  sec-     fibrous  and  miiscular  tissue,  thus  com- 

tion   of  Eustachian  tube.  i    .•  ,i  i         ttt  .i  r 

(After  Zuckerkandi.)  pletmg  the  canal.     We  sec,  therefore, 

that  the  posterior,  superior,  and  a  small 

portion  of  the  anterior  wall  of  the  tube  is  cartilaginous,  while 

the   remainder   of   the   anterior   and    entire    inferior   wall   is 

fibrous,  the  passage  being  slitlike  rather  than  circular  on  cross 


THK    MEMBRANA    TVMl'ANI.  21 

section,  with  the  anterior  and  posterior  walls  in  contact  except 
at  the  up[)er  part.  The  membranous  tube  is  attached  to  the 
inner  extremity  of  the  bonv  canal,  the  posterior  cartilaginous 
plate  uniting  with  a  prt)longation  of  the  corresponding  bony 
wall.  Bevond  the  isthmus  the  tube  is  suspended  from  the 
base  of  the  cranium  bv  fibrous  bands  passing  to  its  superior 
wall,  until  it  terminates  in  the  lateral  aspect  of  the  pharyngeal 
vault. 

As  described  in  the  foregoing  pages,  the  conducting 
mechanism  consists  of  a  canal,  the  walls  of  the  central  por- 
tions being  osseous,  while  at  either  extremity  thev  are  Hbro- 
cartilagin(jus,  communicating  u[)on  one  side  with  the  outer 
surface  of  the  body  directly,  while  upon  the  other  this  com- 
munication is  effected  indirectly  through  the  oral  and  nasal 
passages.  This  tube  is  brought  into  intimate  relation  with 
the  receptive  mechanism  through  the  agency  of  the  ossicular 
chain,  and  at  this  point  the  osseous  conduit  is  dilated,  forming 
the  tympanum.  This  chamber,  situated  midway  in  the  pas- 
sage, is  occupied  by  a  special  device  for  bringing  the  two 
j)ortions  of  the  auditory  apparatus  into  relation  with  each 
other.  For  the  protection  of  the  intratvmpanic  parts  chieilv, 
and,  to  a  certain  extent,  to  aid  in  the  transmission  of  sonorous 
impulses,  a  hbrous  partition  divides  the  external  auditory 
meatus  from  the  tymjtanum  and  Kustachian  tube.  This  parti- 
tion constitutes  the  membrana  tynijiani. 

The  Membrana  Tympani. — The  membrana  tympani  con- 
sists  of  a  transverse  librous  septum,  lying  in  the  middle  of  the 
conducting  tube,  and  bounded  by  the  tympanic  ring,  which, 
it  will  be  remembered,  is  incomplete  at  its  uj)per  i)art.  This 
connective-tissue  lamella,  called  the  substantia  propria  of 
the  drum  membrane,  is  inserted  into  the  sulcus  tympanicus. 
At  the  point  of  insertion  the  fibrous  tissue  is  somewhat  thick- 
ened, formincr  the  annulus  tendinosus,  sometimes  called  the 
cartilaginous  ring.  From  the  cartilaginous  ring  certain 
connective-tissue  fibres  extend  outward  to  the  periosteum  of 
the  meatus,  while  others,  passing  in  the  opposite  direction, 
merge  into  the  periosteal  lining  of  the  tympanum.  The  sub- 
stantia propria  is  made  up  of  two  layers.  In  the  outer  layer 
the  fibres  radiate  from  the  tip  of  the  malleus  toward  the 
peripheral  wall,  while  in  the  internal  layer  they  are  disposed 
in  concentric  circles  about  this  point  as  a  centre.  The  manu- 
brium of  the  malleus  joins  the  substantia  propria  through  the 


22         THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

interposition  of  a  thin  cartilaginous  lamella  which  extends 
along  its  outer  border  from  the  processus  brevis  to  the  umbo, 
the  fibres  of  the  membrane  being  continuous  with  the  peri- 
chondrium of  this  cartilaginous  plate.  At  the  tip  of  the 
manubrium  both  the  circular  and  radiating  fibres  are  attached 
directly  to  the  ossicle,  while  above  this  point,  along  the  ex- 
ternal border,  the  attachment  is  effected  through  the  interpo- 
sition of  the  cartilaginous  plate  above  described.  This  carti- 
lage is  firmly  fixed  at  the  tip  of  the  manubrium,  while  the 
attachment  at  the  short  process  is  less  firm  and  permits  of  a 
certain  amount  of  separation  from  the  short  process.  The 
superior  border  of  the  lamina  propria  joins  the  anterior  and 
posterior  extremities  of  the  annulus  tympanicus,  constituting 
a  tense,  fibrous  band,  divided  by  the  short  process  of  the  mal- 
leus into  two  parts.  The  sharply  defined  superior  margin  of 
the  membrana  propria  extending  from  the  processus  brevis  to 
the  posterior  extremity  of  the  annulus  is  called  the  posterior 
fold  The  corresponding  anterior  fold  is  less  prominent  and 
shorter  than  the  posterior.  From  the  description  it  will  be 
observed  that  the  fibrous  septum  stretched  across  the  canal 
is  wanting  where  the  curved  outline  of  the  annulus  is  com- 
pleted by  the  auditorv  plate  of  the  temporal  bone.  This 
space  is  the  Rivinian  segment  or  notch,  and  its  closure  will 
be  explained  later,  since  it  is  effected  by  the  cutaneous  lining 
of  the  external  auditorv  meatus. 

The  Epithelial  Investment  of  the  Conducting  Apparatus. 
— The  auricle  is  covered  with  integument  which  is  continuous 
with  that  of  the  face.  It  is  somewhat  loosely  attached  upon 
the  posterior  surface,  but  upon  the  anterior  aspect  is  applied 
closely  to  the  cartilage,  the  deep  layer  being  intimatelv  asso- 
ciated with  the  perichondrium.  The  tegumentar}'  covering 
of  the  auricle  is  continued  into  the  external  auditory  meatus, 
its  thickness  decreasing  as  we  pass  inward,  until  in  the  bony 
canal  its  deep  layer  forms  the  periosteum.  The  cutaneous 
lining  of  the  meatus  along  the  supero-posterior  wall  is  thick- 
er and  more  loosely  attached  than  elsewhere,  and  is  richlv 
supplied  with  blood  vessels.  The  covering  of  the  superior 
wall  of  the  canal  passes  from  the  internal  margin  of  the  audi- 
tory plate  to  the  neck  of  the  malleus,  just  above  the  short 
process,  filling  up  the  Rivinian  notch  and  completely  sepa- 
rating the  external  meatus  from  the  tvmpanum.  In  com- 
parison   with    the   remaining   portion  of  the   membrana    tym- 


THK    F.PIIIIELIAL    INVKSTMENT.  23 

pani,  it  hangs  somewhat  U)oselv  from  the  canal  wall,  and  is 
called  the  membrana  tlaccida,  or  Shrapnell's  membrane.  Its 
fibrous  layer  is  particularlv  well  developed  along  the  anterior 
and  posterior  borders,  causing  it  to  assume  a  somewhat  tri- 
angular shape.  These  distinct  fibrous  bands  constitute  the 
fibres  of  Prussak.  They  extend  from  the  anterior  and  pos- 
terior extremities  of  the  Rivinian  segment  to  the  base  of  the 
processus  brevis,  and,  passing  along  the  manubrium,  are  lost 
in  the  external  layer  of  the  membrana  propria.  The  space 
between  the  anterior  ligament  and  the  membrana  flaccida  is 
called  Prussak's  space.  The  epithelial  covering  of  the  meatus 
continues  over  Shrapnell's  membrane,  and  covers  completely 
the  external  surface  of  the  drum  membrane,  forming:  its  ex- 
ternal  or  epithelial  layer.  The  auricle,  the  meatus,  and  the 
superficial  layer  of  the  membrana  thus  constitute  an  elon- 
gated blind  pouch,  not  unlike  the  finger  of  a  glove,  the  drum 
membrane  answering  to  the  closed  tip  of  the  glove  finger. 

The  integument  of  the  auricle  is  supplied  with  sweat 
glands  and  sebaceous  follicles.  In  the  region  of  the  tragus 
and  antitragus,  and  for  some  distance  within  the  cartilaginous 
canal,  hair  follicles  arc  frequently  found.  The  sebaceous 
glands  in  the  meatus  are  somewhat  altered  in  structure,  con- 
stituting the  ccruminous  glands.  These  are  not  distributed 
beyond  the  junction  (jf  the  cartilaginous  meatus  with  the 
osseous  portion,  except  for  a  small  area  along  the  u[)per  and 
posterior  wall,  where  thev  encroach  slightly  uj)on  the  bony 
canal.  The  glands  are  larger  ui)on  the  upper  wall  of  the  canal, 
and  are  most  numerous  at  the  junction  of  the  bony  with  the 
fibro-cartilaginous  porti(  ui. 

The  tvmj)anum  and  Eustachian  tube  are  lined  with  mu- 
cous membrane  continuous  with  that  of  the  naso-pharynx. 
This  membrane  extends  outward  through  the  tube,  covering 
its  walls  and  forming  the  lining  of  the  tympanum.  It  passes 
over  the  internal  surface  of  the  membrana  tympani.  constitut- 
ing its  internal  layer ;  in  various  localities  it  is  folded  upon 
itself  as  it  passes  over  the  various  intratympanic  structures, 
giving  rise  to  the  so-called  reduplications  of  mucous  membrane 
within  the  tympanum.  The  most  constant  of  these  reduplica- 
tions constitute  the  anterior  and  posterior  pockets  of  the  mem- 
brana (Fig.  18).  while  other  folds  whose  location  and  disposi- 
tion are  not  as  constant  are  also  met  with.  The  lining  in  the 
cartilaginous  portion  of  the  Eustachian  tube  is  thick  and  loose- 


24   THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

ly  attached,  being  thrown  into  longitudinal  folds  in  the  lower 
part.  In  the  osseous  tube  and  tympanum  it  is  closely  applied 
to  the  underlying  structures  constituting  the  periosteum.  The 
epithelium  is  of  the  cylindrical  ciliated  variety  in  the  tube  and 
in  the  lower  portion  of  the  tympanic  cavity,  according  to  Po- 
litzer,*  it  changes  to  flat,  ciliated  epithelium  above. 

The  mucous  membrane  is  supplied  with  mucous  glands, 
which  are  extensively  developed  in  the  cartilaginous  tube  near 
the  pharyngeal  orifice,  and  diminish  in  number  in  the  bony 
tube  and  tympanic  cavity.  In  the  middle  ear  they  are  mostly 
confined  to  the  tubal  orifice,  although  they  are  occasionally 
found  over  the  promontory.  The  membranous  portion  of  the 
Eustachian  tube  is  quite  richly  supplied  with  lymphatic  tissue, 
which  occurs  both  in  the  diffuse  form  and,  aggregated  into 
masses,  in  the  form  of  true  lymphatic  nodules.  To  these 
Gerlachf  gives  the  name  of  tubal  tonsil.  The  presence  of 
this  lymphatic  tissue  has  also  been  demonstrated  by  Sappey,:|: 
Ostmann,*  and  Teutleuben.| 

The  Pockets  of  the  Metnbrana  Tympani  and  other  Reduplica- 
tions of  the  Mucous  Membrane  (Figs.  i8  and  19). — The  pockets 
of  the  membrana  tympani  are  the  most  constant  of  the  re- 


FlG.  18. —  1  he  pockets  of  Fig.    ig. —  The   malleo- incudal 

the    membrana    tym-  articulation    covered   by  the 

pani.       (After    Zuck-  superior  malleo-incudal  fold, 

erkandl.)  (After  Zuckerkandl.) 

duplications  which  the  lining  of  the  cavity  forms.  The  mu- 
cous membrane  lining  the  tympanum  is  attached  firmly  to  the 
drum  membrane,  to  the  bony  internal  wall,  and  to  the  walls 
of  the  irregular  spaces  which  lie  between  the  membrana  tym- 
pani and  the  structures  contained  within  the  middle  ear  and 
in  immediate  relation  with  the  membrane.  After  being  re- 
flected over  the  contiguous  bony  and    ligamentous  parts  it 

*  Lehrb.  der  Ohrenheilk.,  Wien,  1S93,  p.  28. 
f  Arch,  fiir  Ohren.,  vol.  x,  p.  53. 

\  Traitd  d'anatomie  descriptive,  Paris,  1877,  p.  865. 

*  Virchow,  Archiv,  vol.  xxxiv. 

\  Zeit.  fiir  Anat.  und  Entwicklungsgeschichte,  1876,  vols,  iii  and  iv,  p.  298. 


INTRATVMl'ANIC    FOLDS.  25 

hangs  downward  into  the  tympanic  cavit\'  in  folds  somewliat 
like  a  curtain.  The  free  borders  of  these  folds  are  sharj)ly 
marked  and  constitute  the  folds  of  the  pockets.  The  anterior 
fold  lies  in  front  of  the  malleus,  and  the  posterior  behind  it. 
The  anterior  pocket  is  the  space  included  between  the  neck 
of  the  malleus  behind,  the  annulus  tvmpanicus  in  front,  the 
membrana  tympani  on  the  outer  side,  and  the  spina  tym- 
panica  major  and  the  anterior  ligament  on  the  inner  side.  At 
its  apex  it  sometimes  communicates  \yith  the  chamber  of 
Prussak.  The  posterior  pocket  is  larger,  and  is  traversed  by 
the  chorda  tympani  nerve  and  the  posterior  ligament  of  the 
malleus.  Its  free  border — the  posterior  fold — may  extend 
downward  as  far  as  the  middle  of  the  manubrium.  This  is  a 
point  of  practical  importance  in  middle-ear  operations,  since 
after  the  division  of  the  membrana  tympani,  this  fold,  if  ex- 
tensive, mav  completely  hide  the  incus,  to  the  l(-)ng  process  of 
which  it  is  frequently  firmly  attached.  1  have  met  with  this 
condition  several  times,  and  unless  one  remembers  the  possi- 
bility of  such  an  anomaly,  its  j)resence  may  prove  a  source  of 
annoyance.  In  one  case  of  exploratory  tympanotomy  per- 
formed under  local  anctsthesia.  the  posterior  fold  was  long, 
thick,  and  adherent  to  the  descending  arm  of  the  incus  and 
to  the  membrana  tymj)ani.  An  incision  through  the  mem- 
brana, instead  of  exposing  the  incud()-staj)edial  articulation, 
brousfht  into  view  a  thick  vascular  lamella  of  mucous  mem- 
branc  which  demanded  repeated  incision  before  the  long  arm 
of  the  incus  could  be  recognized  or  the  inner  wall  of  the  tym- 
panum seen.  In  another  instance  the  fold  was  thin,  but  in- 
vested the  incudo-stapedial  articulation  and  long  arm  of  the 
incus  so  completely  that  exploratory  tympanotomy  revealed, 
immediately  after  displacement  of  the  flap,  nothing  but  a 
smooth,  glistening  surface,  which  appeared  to  be  the  inner 
wall  of  the  middle  ear.  No  landmarks  could  be  made  out;  a 
fact  which  showed  that  the  inner  tympanic  wall  had  not  been 
exposed,  and  it  was  not  until  the  mucosa  was  divided  by  a 
vertical  incision  that  the  promontory  and  the  niche  of  the 
round  window  could  be  seen.  In  acute  inflammatory  condi- 
tions I  have  seen  exudation  encapsulated  in  the  tympanum 
on  account  of  an  anomaly  in  the  posterior  pocket.  The  boun- 
daries of  the  posterior  pocket  will  be  made  clear  by  bearing 
in  mind  those  of  the  anterior  space,  its  exact  analogue. 

The  other  mucous  folds  within  the  tymjianum  will  not  be 


26        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

described  in  detail  on  account  of  their  endless  variety,  but  a 
general  account  of  their  usual  position  and  direction  is  neces- 
sary, since  their  presence  is  often  of  great  importance  both  as 
affecting  the  outcome  of  inflammatory  processes  within  the 
tympanum,  and  increasing  the  difficulty  of  certain  operative 
procedures.  These  folds  differ  from  the  true  ligaments  only 
in  their  density.  They  have  been  extensively  studied  by 
Blake,*  Bryant, f  Zuckerkandl,:}:  and  others. 

In  general  they  may  be  classified,  according  to  their  direc- 
tion, as  vertical  or  horizontal,  and  according  to  their  situation, 
as  those  radiating  from  the  axes  of  the  long  bones,  those  dis- 
posed about  the  stapes  and  the  adjoining  tympanic  walls,  and 
those  stretching  from  the  ossicular  ligaments  and  the  tendons 
of  the  intratympanic  muscles  to  the  ossicles  and  to  the  tym- 
panic walls.  The  horizontal  folds  may  completely  shut  off  the 
vault  of  the  tympanum  from  the  atrium,  and  the  vertical  folds 
may  be  so  extensive  as  to  inclose  the  entire  ossicular  chain 
except  the  manubrium  of  the  malleus. 

The  horizontal  folds  exert  an  important  influence  on  acute 
and  chronic  inflammatory  processes  within  the  middle  ear, 
their  presence  favoring  the  invasion  of  the  mastoid  process 
and  cranial  contents.  The  vertical  folds  not  only  act  as  ob- 
structors to  the  conduction  of  sound  by  their  weight  and  by 
the  increased  tension  which  they  cause,  but  are  of  great  an- 
noyance to  the  surgeon  in  the  performance  of  delicate  opera- 
tions upon  the  tympanum,  as  they  may  completely  hide 
important  structures.  Their  presence,  therefore,  should  be 
borne  in  mind  in  the  consideration  of  all  pathological  pro- 
cesses within  the  middle  ear,  as  in  this  way  many  appear- 
ances which  are  otherwise  inexplicable  may  be  correctly 
interpreted,  or  an  operator  may  be  able  to  accomplish  an  end 
which  a  hasty  view  of  the  cavity  had  led  him  to  believe 
would  be  impossible.  It  need  only  be  remembered  that  no 
hard-and-fast  rule  can  be  given  for  their  location,  and  that 
almost  any  of  the  folds  may  occur  together. 

The  Muscles. — The  muscles  of  the  conducting  mechanism 
include  those  passing  from  the  auricle  to  the  skull,  the  in- 


*  Arch,  of  Otol.,  vol.  xix,  p.  209. 

f  Ibid.,  p.   217.     Burnett's  System  of  Diseases  of  the  Ear,  Nose,  and  Throat, 
Philadelphia,  1893,  vol.  i,  p.  55. 

X  Schwartze's  Handbuch  der  Ohrenheilk.,  Halle,  1893,  vol.  i,  p.  21. 


THE    MUSCLES.  2/ 

trinsic  muscles  of  the  auricle  and  canal,  the  intratvmpanic 
muscles,  and  those  in  the  walls  of  the  Eustachian  tube. 

The  auricle  is  bound  to  the  skull  posteriorly  bv  the  mas- 
toid fascia,  the  fibres  of  which  interlace  with  the  perichon- 
drium and  fibrous  tissue  of  the  canal,  and  anteriorly  by  the 
temporal  fascia,  which  is  firml)-  attached  to  the  helix. 

The  extrinsic  muscles  are  three  in  number,  and  are  unim- 
portant in  man,  though  in  some  of  the  lower  animals  they 
reach  a  high  degree  of  deyelopment.  They  are  the  rctrahens 
aurem,  attollens  aurem,  and  attrahens  aurem. 

The  retraliens  arises  from  the  mastoid  region  by  short 
aponeurotic  fibres,  and  is  inserted  into  the  cartilage  of  the 
auricle  upon  its  posterior  and  inferior  aspect.  Its  point  of 
origin  is  fixed  only  when  the  occipital  portion  of  the  occipito- 
frontalis  is  rigid. 

The  attrahens  arises  from  the  epicranial  aponeurosis  at  its 
lower  border,  and  is  inserted  \\\Uy  the  spine  of  the  helix  upon 
its  cranial  surface. 

The  at  to/lens  arises  from  the  occipito-frontalis  aponeuro- 
sis. The  fibres  converge  to  the  point  of  insertion  upon  the 
upper  part  of  the  cranial  surface  of  the  auricle. 

The  intrinsic  musc/es  consist  of  poorly  developed  bundles 
of  muscular  fibres  distributed  between  the  various  cartilagi- 
nous processes  oi  the  auricle.  Theoretically,  their  action 
would  serve  to  alter  the  shape  of  the  ])inna,  but  from  their 
imperfect  development  they  are  unimportant.  They  are 
situated  chiefly  upon  the  external  surface  of  the  organ.  In 
the  external  meatus  a  few  fibres  of  muscular  tissue  are  found 
mixed  with  the  fibrous  bands  which  fill  the  incisures  of  San- 
torini. 

A  muscular  slip  is  occasionally  found  extending  from  the 
styloid  process  upward  to  the  cartilaginous  meatus. 

The  intratyvipanic  muscles  are  the  tensor  tympani  and  the 
stapedius. 

The  tensor  arises  from  the  upper  wall  of  the  cartilaginous 
Eustachian  tube  and  from  the  walls  of  the  bony  canal  which 
inclose  it.  It  enters  the  middle  ear  through  an  osseous  con- 
duit at  a  point  just  above  the  tympanic  orifice  of  the  Eu- 
stachian tube,  from  which  it  is  separated  by  a  thin  plate  of 
bone — the  processus  cochleariformis.  The  tympanic  extrem- 
ity of  this  process  is  pyramidal  in  shape,  and  is  often  called 
the  anterior  pyramid.     The  tendon  winds  about  this  projec- 


28        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

tion  almost  at  a  right  angle,  crosses  the  cavity  of  the  middle 
ear,  and  is  inserted  along  the  inner  border  of  the  shaft  of  the 
malleus  just  below  the  neck,  some  of  the  fibres  passing  for  a 
considerable  distance  down  the  manubrium,  and  spreading 
somewhat  upon  its  anterior  surface. 

The  stapedius  arises  from  the  interior  of  the  pyramid 
found  upon  the  postero-internal  tympanic  wall  in  front  of 
and  below  the  aqueductus  Fallopii.  The  fibres  converge 
into  a  tendon  which  pierces  the  apex  of  the  pyramid  and  is 
inserted  into  the  neck  of  the  stapes  at  the  point  of  union  with 
the  posterior  crus. 

The  muscles  of  the  Eustachian  tube  are  the  tensor  palati,  or 
spheno-salpingo-staphylinus,  and  the  levator  palati,  or  petro- 
salpingo-staphylinus. 

The  tensor  palati  exerts  the  most  influence  upon  the  lumen 
of  the  Eustachian  canal.  It  arises  from  the  scaphoid  fossa 
and  spine  of  the  sphenoid  bone  in  front  of  the  membranous 
portion  of  the  tube,  some  of  its  fibres  springing  from  the  in- 
ferior border  of  the  cartilaginous  hook.  The  muscle  then 
passes  downward  in  front  of  the  membranous  portion  of  the 
canal,  converging  into  a  tendon  which  winds  around  the 
hamular  process  of  the  sphenoid  and  expands  into  a  broad 
aponeurosis  which  is  inserted  into  the  anterior  surface  of  the 
soft  palate  and  into  the  posterior  bony  margin  of  the  hard 
palate,  the  fibres  uniting  with  those  of  the  opposite  side  in 
the  median  raphe. 

The  levator  palati  springs  from  the  quadrilateral  surface 
on  the  inferior  aspect  of  the  petrous  bone,  near  its  apex,  and 
passes  downward,  forward,  and  inward  to  its  insertion  on  the 
posterior  and  superior  surface  of  the  soft  palate.  The  body 
of  the  muscle  lies  along  the  inferior  margin  of  the  cartilagi- 
nous plate  which  forms  the  posterior  wall  of  the  tube,  to 
which  it  is  loosely  attached.  It  is  also  in  contact  with  the 
fibrous  inferior  wall. 

A  third  muscle,  sometimes  included  in  this  group,  is  the 
salpingo-pharyngeus,  a  muscular  slip,  which  runs  from  the 
body  of  the  palato-pharyngeus  upward  and  forward  to  be 
inserted  into  the  inferior  wall  of  the  tube. 

The  Arteries  (Plate  I)  of  the  conducting  apparatus  are  de- 
rived chiefly  from  the  external  carotid  artery,  although  a  few 
branches  spring  from  the  internal  carotid.  The  branches  of 
the  external  carotid  supplying  the  auricle,  canal,  and  middle 


PLATE 


The  Artkrial  Supi-ly  of  the  Conductinc  Ai'Pakatus. 


THi:    ARTERIES.  29 

ear  are  the  posterior  auricular,  the  superficial  temporal,  the 
occipital,  the  internal  niaxiliarv.  and  the  ascendin^^  pharyn- 
geal. 

The  posterior  auricular  is  distributed  to  the  posterior  por- 
tion of  the  auricle  and  the  corresponding-  part  of  the  meatus. 
Through  the  stylomastoid  branch  which  enters  the  stylo- 
mastoid foramen  it  supplies  the  mastoid  cells,  and  sends  a 
special  branch  to  the  stapedius  muscle  and  to  the  stapes.  It 
anastomoses  with  the  superficial  petrosal  of  the  middle  me- 
ningeal artery  within  the  tympanic  cayity,  and  w  ith  the  tym- 
j)anic  branch  of  the  internal  maxillary,  forming  with  this  lat- 
ter a  complete  yascular  circle  about  the  inner  extremity  of 
the  meatus. 

The  superficial  temporal,  through  the  superior  and  infe- 
rior anteritjr  auricular  arteries,  supplies  the  anterior  j)ortion 
oi  the  j)inna  and  canal,  the  vessels  anastomosing  with  the 
branches  of  the  posterior  auricular  artery;  it  also  sends  a 
small  branch  to  the  tympanum  through  the  Glaserian  fissure. 

The  occipital  artery  sends  branches  to  the  concha,  the  ves- 
sels entering  upon  its  cranial  surface. 

Thi  internal  tnaxillary,  through  the  middle  meningeal  and 
tympanic  branches,  is  the  most  important  source  of  blood 
supply,  especially  in  early  life.  Before  entering  the  cranium 
it  sends  a  few  twigs  to  the  Eustachian  tube.  Within  the 
skull  it  gives  off  the  superficial  petrosal,  which  enters  the 
tympanum  through  the  petro-squamous  suture,  and  is  dis- 
tributed to  the  roof  of  the  middle  ear,  to  the  malleus  and 
incus,  and  to  a  portion  of  the  internal  tympanic  wall,  where 
it  anastomoses  with  the  labyrinthine  vessels,  according  to 
Politzer.*  Within  the  Fallopian  canal  it  communicates  with 
the  stylomastoid  branch  of  the  posterior  auricular. 

The  tympanic  branch  of  the  internal  maxillary  enters  the 
middle  ear  through  the  Glaserian  fissure,  supplying  the  ante- 
rior portion  of  the  cavity,  and  anastomoses  with  the  stylo- 
mastoid branch  of  the  posterior  auricular  upon  the  periph- 
ery of  the  tympanic  membrane.  In  early  life  this  artery  is 
much  larger  than  the  stylomastoid,  and  the  vascular  circle 
about  the  margin  of  the  membrane  from  which  the  numerous 
vessels  pass  outward  to  the  posterior  wall  of  the  meatus 
seems  to  spring  from  the  tympanic  branch  of  the  internal 

*  Archiv  fiir  Ohrenheilk.,  vol.  xl,  p.  237. 


30    THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

maxillary  ;  hence  this  artery  is  sometimes  called  the  auricu- 
laris  profunda. 

On  the  internal  wall  of  the  middle  ear  the  tympanic  artery 
anastomoses  with  the  tympanic  branches  of  the  internal  carotid 
and  with  the  Vidian  branch  of  the  internal  maxillary.  In  ad- 
dition to  the  two  branches  of  the  internal  maxillary  named 
above,  the  Vidian,  the  descending  palatine,  and  the  pterygo- 
palatine arteries,  all  springing  from  this  trunk,  send  small 
vessels  to  the  Eustachian  tube  and  to  the  tubal  muscles ;  the 
descending  palatine  anastomoses  freely  with  the  ascending 
palatine  branch  of  the  facial  and  with  the  ascending  pharyn- 
geal branch  of  the  external  carotid  artery. 

In  its  passage  through  the  carotid  canal  the  internal  carotid 
sends  branches  to  the  tympanum,  which  anastomose  with  the 
tympanic  and  Vidian  branches  of  the  internal  maxillary. 

The  Veins  (Plate  II). — The  veins  are  rather  irregular  in 
their  distribution,  but  in  general  follow  the  course  of  the  arter- 
ies. Most  of  the  vessels  from  the  deeper  regions  form  a  plexus 
upon  the  superior  and  supero-posterior  walls  of  the  external 
auditory  meatus ;  as  they  approach  the  orifice  of  the  meatus 
the  various  venous  channels  anastomose  freely  with  one  an- 
other. Those  on  the  posterior  aspect  of  the  canal  and  auricle 
pass  into  the  external  jugular  and  mastoid  veins,  while  the  an- 
terior branches  go  to  join  the  temporal  and  facial  veins.  Some 
of  the  deeper  vessels  pass  into  the  pterygoid  plexus.  The 
veins  of  the  Eustachian  tube  follow  the  course  of  the  arteries 
distributed  to  this  region,  and  empty  into  the  internal  jugular 
directly,  or  occasionally  communicate  with  the  facial,  the 
lingual,  or  the  superior  thyroid  veins.  Between  the  internal 
pterygoid  muscle  and  the  adjacent  wall  of  the  tube  a  trunk  of 
considerable  size  establishes  communication  with  the  cavern- 
ous sinus ;  near  the  pharyngeal  orifice  of  the  Eustachian  ca- 
nal there  is,  according  to  Zuckerkandl,*  a  venous  plexus  com- 
municating with  the  turbinated  bodies  in  the  nasal  cavities. 
The  free  anastomosis  of  the  veins  which  return  the  blood 
from  the  deeper  portions  of  the  conducting  mechanism  is  of 
particular  importance  from  a  therapeutic  point  of  view,  since 
this  intercommunication  between  the  various  channels  is 
comparatively  superficial,  and  enables  us  to  relieve  deep- 
seated   congestion   by   phlebotomy.     The  combined  area   of 

*  op.  cit.,  p.  38. 


PLATE    II. 


Tin:  Venous  .Sijppi.y  of  thf.  Conducting  Apparatus. 


THE    LYMPHATICS    AND    NERVES. 


31 


the  veins  is  much  greater  than  that  of  the  arteries — a  fact 
which  in  itself  tends  to  cause  the  spontaneous  resolution  of 
anv  inflammatory  process  which  may  arise.  Within  the  tym- 
panum the  circulatory  arrangement  is  somewhat  unique,  the 
capillaries  being  very  short,  or  entirely  wanting,  and  the 
arterial  blood  passes  directly  into  the  veins  without  the  inter- 
position of  the  capillary  system,  as  demonstrated  by  Prussak.* 

The  Lymphatics. — The  lymphatic  channels  are  freelv  dis- 
tributed and  anastomose  both  with  the  superficial  lymph  glands 
and  with  those  forming  the  submucous  lymphatic  system  of 
the  pharynx.  The  superficial  lymphatics  over  the  mastoid, 
the  lymph  nodules  in  front  of  the  auricle,  and  those  situated 
in  the  cervical  region  between  the  platysma  and  the  sterno- 
mastoid  muscles  are  all  intimately  associated  with  the  lym- 
phatic channels  of  the  meatus  and  tympanum,  while  free 
Ivmphatic  anastomosis  exists  in  the  opposite  direction  through 
the  medium  of  the  glands  situated  in  the  lateral  pharyngeal 
walls.  The  Ivmph  channels  of  the  membrana  tvmpani  itself 
are  arranged  in  three  systems,  one  for  each  layer.  These 
communicate  freelv  with  each  other  and  with  the  lymj)hatic 
network  of  the  external  meatus. 

The  Nerves  (Figs.  20  and  21). — The  muscles  of  the  con- 
ducting apparatus  derive  their  innervation  from  the  trigem- 
inus, the  facial,  and  the  cervical  plexus.  The  cervical  plexus, 
through  the  occipitalis  minor,  supplies  the  attollens  aurem  ; 
the  trigcuiiuus,  through  the  otic  ganglion,  supplies  the  tensor 
tympani  and  the  tensor  palati  muscles  ;  the  facial  supplies 
the  other  muscles,  either  directly  or  through  its  ganglionic 
communications. 

The  sensory  nerves  are  derived  from  the  cervical  plexus, 
trigeminus,  pneumogastric,  and  the  glosso-pharyngeal  trunks. 
The  aiiriculo-temporaL  a  branch  of  the  trigeminus,  supplies 
the  auricle,  the  upper  part  of  the  meatus,  and  the  membrana 
tympani.  The  auricularis  uiagniis,  from  the  cervical  plexus, 
is  distributed  principallv  to  the  posterior  part  of  the  auricle 
and  meatus,  anastomosing  with  the  auricular  branch  of  the 
pneumogastric  upon  the  posterior  wall  of  the  canal. 

The  auricular  branch  of  the  vagus  supplies  the  cartilagi- 
nous canal  and  a  portion  of  the  posterior  surface  of  the  auricle. 
The  tympanic  branch  of  the  glosso-pharyngeal  enters  the  mid- 

*  Archiv  fiir  Ohrenheilk.,  vol.  iv,  p.  2go. 


32    THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

die  ear  through  a  foramen  in  the  floor  of  the  cavity,  and 
is  distributed  to  its  lining  membrane  and  to  the  Eustachian 
tube.  Upon  the  internal  tympanic  wall  it  divides.  One 
branch  anastomoses  with  the  fibres  of  the  carotid  plexus  from 
the  sympathetic  system,  forming  the  tympanic  plexus ;  an- 
other nerve  twig,  the  small  deep  petrosal,  passes  through  a 
bony  foramen  in  the  tegmen  tympani  to  the  small  superficial 
petrosal  nQTwc,  which  is  the  facial  tributary  to  the  otic  ganglion  ; 
a  third  emerges  from  the  cavity  to  join  the  great  superficial 
petrosal,  which  is  the  facial  root  of  the  Vidian  nerve,  the  pos- 
terior branch  of  Meckel's  ganglion.  This  branch  is  called 
the  great  deep  petrosal. 

Briefly,  we  may  describe  this  complex  nervous  anastomo- 
sis as  follows :  The  glosso-pharvngeal,  through  its  tympanic 


Fig.  20. — The  nerves  of  the  conducting  mechanism,  and  tlieir  anastomotic  brandies. 

branch,  anastomoses  with  branches  from  the  carotid  plexus, 
upon  the  internal  wall  of  the  middle  ear,  forming  tiie  tym- 
panic plexus ;  from  this  plexus  two  branches  are  given  off, 
one  communicating  with  the  otic  ganglion,  the  other  with 
Meckel's  ganglion. 

We  have  yet  to  mention  the  chorda  tympani,  which,  emerg- 
ing from  the  aquaeductus  Fallopii  above  the  p3^ramid,  crosses 
the  tympanic  cavity  from  behind  forward,  passing  between  the 
long  process  of  the  incus  and  the  manubrium  of  the  malleus. 
It  leaves  the  middle  ear  through  a  separate  canal  which  lies 


THE    RKCEPTINE    MECHANISM.  33 

close  to  the  Glaserian  fissure,  and  joins  the  lingual  branch  ot 
the  trigeminus. 

It  can  not  but  be  noticed  how  richly  the  conducting  ap- 
paratus of  the  ear  is  sujiplied  with  nerves,  especially  in  the 
deeper  and  more  delicate  parts.  More  will  be  said  upon  this 
subject  in  considering  the  physiology  of  the  conducting  mech- 


FlG.  21. — The  nerve  distribution  within  the  tympanum. 

anism.  but  the  free  anastomosis  between  the  various  nerves 
should  be  particularly  borne  in  mind,  for  it  is  due  to  this  fact 
that  changes  within  the  external  or  middle  ear  or  Eustachian 
tube  may  give  rise  to  remote  symjitoms,  and  that  these  re- 
gions may  themselves  be  the  seat  of  reflex  disturbances.     • 

11.    The  Rkcki'tive  iMechamsm. 

We  have  now  described  that  part  of  the  ap|)aratus  of 
audition,  concerned  in  the  transmission  of  sonorcjus  vibrations 
from  without,  to  the  point  where  they  are  brought  into  im- 
mediate relation  with  the  end  organ  of  the  auditory  nerve. 
Let  us  next  consider  the  structures  concerned  in  the  inter- 
pretation of  these  sonorous  vibrations. 

For  reasons  already  given,  we  include  under  this  general 
term,  not  only  the  internal  ear,  but  also  the  auditory  nerve 
and  its  centers  of  oriofin,  as  well  as  the  various  avenues  of 
communication  with  other  centers,  and  with  the  correspond- 
ing nuclei  of  the  opposite  side  and  with  the  cortical  area  of 
audition  in  the  brain. 
4 


34        THE    ANATOMY    AND    PHYSIOLOGY   OF   THE    EAR. 

For  convenience  of  description,  the  course  of  the  auditory 
nerve  will  be  followed  from  the  specialized  end  organ  found 
in  the  labyrinth,  inward  toward  its  origin,  rather  than  in  the 
opposite  direction,  which  would  be  more  strictly  correct  from 
an  anatomical  point  of  view. 

The  internal  ear  comprises  the  osseous  and  membra- 
nous labyrinth,  the  former  being  a  series  of  communicating 
chambers  tunneled  in  the  petrous  portion  of  the  temporal 
bone  and  filled  with  fiuid,  in  which  the  membranous  labyrinth 
is  suspended.  This  latter  structure  consists  of  a  series  of 
membranous  tubes,  also  filled  with  fluid,  called  the  endolymph. 
They  follow  the  general  contour  of  the  osseous  passages  in 
which  they  lie,  but  do  not  completely  fill  them,  the  interven- 
ing space  being  occupied  bv  the  perilymph. 

The  Bony  Labyrinth  (Fig.  22). — The  bony  labyrinth  may 
be  described  as  a  central  chamber  in  the  petrous  portion  of 


Flc.  22. —  rhe  bony  labyrinth.  (Riidinger,  Blake's  translation.)  i,  Round  window; 
2,  Lamina  spiralis  ossea ;  3,  t)sseous  cochlear  canal  ;  4,  Floor  of  internal  audi- 
tory meatus  ;   5,  Vestibule  ;  6,  7,  8,  9,  Semicircular  canals. 

the  temporal  bone,  called  the  vestibule,  from  which  various 
tortuous  channels  diverge.  This  central  chamber  is  ovoid  in 
shape,  the  vertical  diameter  being  the  greater  and  measur- 
ing about  one  fourth  of  an  inch,  while   the  short  diameter  is 


THE    HONY    LABYRINTH.  35 

about  one  fifth  of  an  inch.  On  its  outer  wall  it  presents  a 
kidney-shaped  opening,  which  under  normal  conditions  is 
closed  by  the  foot  plate  of  the  stapes.  The  inner  wall  ex- 
hibits two  fossa:?,  separated  by  a  bony  spine  called  the  crista 
vestibuli.  The  anterior  depression,  which  is  occupied  bv  the 
saccule,  is  the  recessus  sphericus;  the  posterior,  lodging;  the 
utricle,  is  the  recessus  ellipticus.  The  posterior  wall  presents 
the  openins^s  of  the  three  semicircular  canals;  these  opcning^s 
are  five  in  number,  two  canals,  the  superior  and  ])ostcrior 
entering  the  vestibule  by  a  common  channel.  The  entrance 
to  the  cochlear  canal  takes  the  place  of  the  anterior  wall  of  the 
vestibule.  On  the  inferior  internal  wall,  close  to  the  border 
of  the  recessus  ellipticus,  there  is  a  small  opening,  the  orifice 
of  the  acjuieductus  vestibuli.  Through  this  channel  the  cav- 
ities of  the  membranous  labvrinth  communicate  with  the 
subdural  space. 

The  simicirciilar  canals  are  three  in  luimber.  and  are  so 
disposed  that  the  j)lane  of  each  canal  is  perpendicular  to 
that  of  the  other  two;  thev  are  denominated  the  sujierior, 
posterior,  and  external  canals.  The  superior  lies  in  the  ver- 
tical plane  of  the  long  axis  of  the  j)etrous  portit)n  of  the 
tenijioral  bone.  The  posterior  is  placed  at  right  angles 
to  this,  and  is  also  vertical,  while  the  external  canal  lies  in 
the  horizontal  |>lane.  As  the  name  implies,  each  of  these  bony 
passages  bends  upon  itself  to  form  a  semicircle,  the  point  of 
origin  and  termination  being  the  vestibule.  The  superior 
and  posterior  canals  terminate  in  this  cavity  by  a  common 
opening,  but  with  this  exception  each  communicates  with  the 
vestibule  bv  two  openings,  one  of  which  may  be  considered 
the  source  and  the  other  the  terminus.  Where  the  outer  ex- 
tremity of  the  external  canal  enters  the  vestibule  the  lumen 
of  the  passage  becomes  dilated,  forming  what  is  known  as  an 
ampulla.  The  unioined  vestibular  extremities  of  the  posterior 
and  superior  canals  arc  also  ampullatcd. 

The  Cochlea. — The  entrance  of  this  passage  lies  at  the 
anterior  and  inferior  aspect  of  the  vestibule.  It  consists  of  a 
bonv  tube  coiled  two  and  a  half  times  about  an  osseous  axis 
— the  modiolus.  From  the  modiolus  a  thin  septum  of  bone 
— the  lamina  spiralis — made  up  of  two  thin  bony  plates,  ex- 
tends into  the  lumen  of  the  tube,  partially  dividing  it  into 
two  channels.  This  bonv  partition  does  not  extend  com- 
pletelv  across    the  canal    to  the  outer    wall,  the  intervening 


6        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 


space  being  bridged  by  a  membranous  septum,  which  com- 
pletes the  division  of  the  cochlear  tube.  This  fibrous  septum 
is  called  the  lamina  spiralis  membranacea.  The  lamina  spi- 
ralis at  its  free  border  divides  into  a  superior  and  inferior 
limbus.  The  space  inclosed  by  this  separation  is  called  the 
sulcus  laminae  spiralis.  At  the  apex  of  the  cochlea  the  par- 
tition which  divides  the  canal  into  two  distinct  channels  is 
incomplete ;  the  termination  of  the  septum  is  somewhat 
hook-shaped,  forming  the  hamular  process,  while  the  passage 
of  communication  between  the  superior  and  inferior  spaces 
is  called  the  helicotrema.  The  terminal  half-turn  of  the  coch- 
lea forms  the  cupola,  and  in  this  region  the  lamina  spiralis 
ossea,  just  before  its  termination,  is  twisted  upon  itself  in 
such  a  manner  as  to  inclose  a  funnel-shaped  space  called 
the  infundibulum. 

The  modiolus  is  traversed  by  numerous  canals,  the  larg- 
est running  through  its  axis  and  named  the  canalis  cen- 
tralis modioli,  from  which  secondary  channels  diverge  into 
the  lamina.  At  the  junction  of  the  modiolus  with  the  lamina 
a  canal  ascends  spirally  between  the  layers  of  this  bony  sep- 
tum, passing  to  the  very  apex  of  the  cochlea.  This  is 
called  the  canalis  spiralis  modioli.  The  lamina  spiralis  ossea, 
with  the  membranous  lamina,  divides  the  bony  cochlea  into 
two  passages,  as  already  stated.  The  lower  is  called  the 
scala  tympani,  the  upper  the  scala  vestibuli.  The  modiolus 
and  the  lamina  are  so  disposed  that  the  scala  tympani  does 
not  communicate  with  the  vestibule,  but  leads  into  the  tym- 
l)anic  cavitv  at  the  round  window.  In  fact,  we  may  consider 
the  cochlear  canal  as  beginning  at  the  fenestra  rotunda,  at  the 
inferior  external  angle  of  the  vestibule,  the  wall  at  this  point 
forming  the  modiolus.  As  the  first  turn  passes  forward  and 
then  upward  from  the  round  window,  the  contiguous  walls  of 
the  tube  and  of  the  vestibule  amalgamate  and  form  a  partition 
extending  into  the  tube,  which  divides  it  into  two  channels, 
the  upper  of  which  communicates  with  the  vestibule.  The 
bonv  partition  thus  formed  does  not  extend  entirely  across 
the  tube,  and  the  septum  is  completed  by  the  membranous 
spiral  lamina.  Just  beyond  the  round  window  in  the  floor  of 
the  scala  tvmpani  a  narrow  canal  extends  to  the  inferior  sur- 
face of  the  petrous  bone.  This  is  the  aqutcductus  cochleae,  and 
can  be  traced  to  the  subarachnoid  lymph  space;  it  affords  an 
avenue    of    communication    between   the   perilymph  and  the 


THK  MKMHRANOrS  I.AnVRINTH.  37 

intracranial  Ivmph  sac.  After  the  lamina  spiralis  ossea  sepa- 
rates into  two  thin  plates  of  bone,  each  is  continued  as  a 
membranous  septum  as  far  as  the  outer  wall  of  the  cochlea. 
Here,  by  their  divergence,  thev  inclose  a  triangular  space, 
which  extends  from  the  round  window  to  the  apex  t)f  the 
cochlea,  in  a  spiral  direction  ;  this  space,  converted  into  a  tube 
by  the  outer  wall  of  the  cochlea,  is  called  the  cochlear  canal 
or  scala  media.  Where  the  diverging  septa  join  the  outer 
bonv  wall  of  the  cochlea  the  periosteum  is  thickened  and 
richly  supplied  w^ith  blood  vessels,  especially  where  it  joins 
the  lower  lamella,  where  it  is  called  the  ligamentum  sj)irale. 

That  portion  of  the  membranous  septum  which  is  con- 
tinuous with  the  inferi(jr  lamella  of  the  osseous  spiral  lamina 
passes  outward  in  the  same  jtlane  as  the  lamina  spiralis  ossea, 
and  becomes  the  membrana  basilaris.  The  up|)cr  leaflet 
forms  an  acute  angle  with  this,  and  is  called  the  membrane  of 
Reissner. 

The  manner  of  formation  and  the  course  of  the  various 
channels  having  been  described,  we  have  next  to  consider 
the  lining  membrane. 

The  walls  of  the  osseous  canals  and  vestibule  are  ccjvered 
bv  delicate  tibrillated  connective  tissue  rich  in  nuclear  ele- 
ments ;  this  is  applied  closely  to  the  osseous  walls,  constituting 
the  periosteum.  Its  surface  is  covered  with  flat  endothelial 
cells.  The  lumen  of  the  bonv  semicircular  canals  or  peri- 
Ivmphatic  space  is  traversed  by  delicate  bands  of  the  con- 
nective-tissue covering  of  the  osseous  walls,  which  pass  to  the 
outer  wall  of  the  membranous  canals,  thus  dividing  the  peri- 
Ivmphatic  space  irrcgularlv.  At  the  point  of  attachment  of 
the  membranous  canals  to  the  walls  of  the  passage  their  lin- 
ing membrane  is  thickennl. 

The  Membranous  Labyrinth  (Fig.  23). — The  membranous 
labyrinth  consists  of  a  series  of  tubes,  formed  of  delicate  con- 
nective tissue,  lying  within  the  bony  channels  already  de- 
scribed. The  membranous  simicircular  canals  terminate  in  the 
utricle,  which  lies  in  the  recessus  ellipticus  vestibuli.  while  the 
membranous  cochlea  is  joined  to  the  saccule  by  a  very  narrow 
canal,  called  the  canalis  reuniens  Hensenii.  This  entire  series 
of  tubes  is  filled  with  a  clear  fluid  known  as  the  endolymph. 
Thus  far  we  have  described  two  series  of  channels,  contain- 
ing fluid,  terminating  in  somewhat  spherical  chambers — the 
utricle  and  saccule.     The  membranous  cochlea  terminates  in 


38        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

a  blind  pouch  (the  lagena)  at  the  apex  of  the  bony  passage 
in  which  it  lies.  From  the  adjacent  aspects  of  the  utricle  and 
saccule  a  delicate  canal  is  given  off  which  coalesces  into  a 
common  channel — the  ductus  endolymphaticus.  This  trav- 
erses the  aqureductus  vestibuli  and  terminates  in  a  blind  sac 
(the  recessus  of  Cutogno)  upon  the  posterior  surface  of  the 
petrous  bone  beneath  the  dura.  According  to  RUdinger,* 
the  endolymph  may  pass  to  the  dural  lymph  spaces  through 
this  canal.     The  saccule  and  utricle  lie  upon  the  internal  wall 


Fig.  23. — Adult  membranous  labyrinth  (osmic-acid  preparation).  (Retzius.)  /,  La- 
gena ;  lis.  Spiral  ligament ;  mb.  Basilar  membrane  ;  sv.  Stria  vascularis  ;  mts, 
Membrana  tympani  secundaria  ;  esc,  Canalis  reuniens  ;  s.  Lower  end  of  saccule  ; 
ctis,  Canalis  utriculo-saccularis  ;  dr.  Ductus  endolymphaticus  ;  j/,  I'osterior  utricu- 
lar sinus  ;  rec,  Recessus  ufriculi  ;  aa,  at',  ap,  Ampullne  of  anterior,  external,  and 
posterior  canals  ;  vb.  Vestibular  cul-de-sac  :  ca,  cc,  cp.  Semicircular  canals  ;  ss. 
Union  of  posterior  and  superior  canals  ;  rb,  rap,  rs,  rti,  raa,  rac.  Branches  of 
auditory  nerve  to  various  portions  of  membranous  labyrinth  ;  ms.  Macula  acus- 
tica  of  saccule  ;  f.  Facial  nerve. 

of  the  bony  vestibule,  but  do  not  fill  the  cavity  completely, 
considerable  space  being  left  between  them  and  the  outer 
wall.  The  intervening  space  is  filled  with  perilymph,  and  is 
called  the  cisterna  l^-mphatica.  It  is  of  practical  importance 
to  remember  that  the  distance  from  the  inner  surface  of  the 
foot  plate  of  the  stapes  to  the  opposite  wall  of  the  membra- 
nous labyrinth  is  about  three  millimetres,  or  one  eighth  of  an 
inch.     In  the   same  manner  the  lumen  of  the  bony  cochlea 


*  .\rch.  fiir  Ohrenheilk.,  vol.  xxvii,  p.  222. 


THE    SACCLL1-:    AND    U  FRICLK.  39 

and  semicircular  canals  is  not  completely  filled  bv  the  con- 
tained membranous  structures;  these  latter  are  attached  to 
the  bony  walls  along  the  line  of  their  convexity,  and  the 
periosteum  is  thickened  along  this  line.  Additional  support 
is  aftorded  the  semicircular  canals  bv  bands  of  connective 
tissue  which  pass  from  the  outer  wall  of  the  membranous 
channel  to  the  osseous  walls. 

Regarding  the  microscopical  structure  of  the  membranous 
labyrinth,  it  may  be  described  as  made  up  of  a  framework  of 
connective  tissue,  the  outer  surface  being  covered  by  a  reflec- 
ti<in  of  the  endothelial  layer  which  lines  the  bony  labyrinth. 
The  lining  of  the  irregular  cavity  is  of  much  greater  interest, 
since  it  constitutes  the  special  end  organ  ot  the  auditory 
nerve. 

Tlw  Saccule  and  UtricU-. — Upt)n  the  internal  surface  of  the 
saccule  and  utricle,  in  the  region  corresponding  to  their  at- 
tachment to  the  bony  vestibular  wall,  there  is  a  mound  or 
papilla  which  encroaches  somewhat  uj)(jn  the  luiuen  of  the 
cavity.  This  papilla  is  called  the  macula  acustica,  and  is 
formed  by  the  aggregation  of  the  cells  which  form  the  lining 
of  the  space,  the  epithelium  clianging  frcjm  the  jxjlygonal 
pavenunt  variet\-  to  the  cuboidal.  and  then  to  the  cylin- 
drical form  as  it  aj)pr()aches  the  region  of  the  macula.  The 
papilla  itself  is  covered  by  a  specialized  ej)ithelium,  the  cells 
appearing  under  two  forms,  either  as  ciliated  or  hair  cells,  or 
as  supporting  cells  placed  between  those  before  named.  The 
supporting  cells  have  large  nuclei,  and  are  either  cuboidal  be- 
low near  the  base,  sending  a  delicate  process  to  the  surface, 
or  they  arc  fusiform,  the  nucleus  lying  near  the  centre.  They 
terminate  in  elongated  processes,  one  of  which  lies  upon  the 
surface  of  the  papilla,  the  other  passing  to  the  basement 
membrane. 

The  hair  cells  are  elongated  protoplasmic  masses,  each 
with  an  ovoid  base,  from  which  the  body  gradually  tapers  to 
a  constricted  portion  called  the  neck,  just  below  the  superior 
extremity  ;  above  this,  the  cell  again  becomes  broad.  From 
the  free  extremity  of  each  cell,  ten  to  twelve  cilia?  project 
into  the  cavity;  these  are  called  the  auditory  hairs.  Ac- 
cording to  Kaiser,*  whose  description  I  have  most  closely 
followed   here,  the  body  of  each  hair  cell  is  completely  sur- 

*  Arch    fUr  Ohrenheilk.,  vol.  xxxii,  p.  181. 


40        THE    ANATOMY   AND    PHYSIOLOGY   OF   THE    EAR. 

rounded  by  a  delicate  envelope,  formed  by  the  expansion  of  the 
axis  cylinder  of  a  single  nerve  fibrilla,  although  the  axis  cylinder 
cannot  be  traced  with  certainty  into  the  cell  body.  The  sur- 
face of  the  macula  acustica  constitutes  the  membrana  limitans; 
this  is  reticular  in  structure,  and  through  its  spaces  the  audi- 
tory hairs  project.  In  hardened  specimens  the  auditory  hairs 
are  usually  matted  together,  and  the  macula  appears  to  be  cov- 
ered bv  a  finely  fibrillated  gelatinous  substance,  in  which  some 
of  the  ciliary  processes  can  be  made  out.  Lying  between  the 
cilias,  upon  the  surface  of  the  macula  we  find  an  aggregation 
of  minute  crystals — the  otoliths — apparently  imbedded  in  the 
structureless  covering  of  the  mound.  The  agglutination  of  the 
auditory  hairs  is  probably  due  to  changes  effected  in  the  en- 
dolymph  bv  fluids  used  in  hardening  the  specimens.  The 
macula  acustica  of  the  utricle  and  saccule  are  identical  in 
structure.  In  the  ampullce  similar  papillae  are  found,  and  are 
here  called  the  cristoe  acusticce.  The  cristcC  acusticae  arc 
smaller  than  the  maculae  acustica?,  their  hair  cells  are  also 
less  developed,  and  the  individual  cilia^  can  not  be  made  out. 
In  hardened  specimens  the  apex  of  the  crista  has  the  same 
structureless  appearance  as  that  of  the  macula,  the  homo- 
geneous substance  surmounting  it  being  here  called  the  cu- 
pula. The  appearance  is  probably  due  to  the  action  of  the 
hardening  fluids  upon  the  endolymph.  The  membranous 
canals  are  lined  with  polygonal  pavement  epithelium,  and 
present,  at  various  portions  of  their  course,  a  papillary  struc- 
ture. No  nerve  elements  have  been  traced  to  the  interior  of 
the  canals. 

The  Membranous  Cochlea  or  Scala  Media. — This  passage  is 
joined  to  the  saccule  by  the  canalis  reimiens  Hensenii,  and 
consists  of  a  membranous  tube,  triangular  on  cross  section, 
inclosed  between  the  membrane  of  Reissner  above,  and  the 
membrana  basilaris  below.  Its  outer  wall  is  formed  by  the 
endothelial  lining  of  the  bony  cochlea.  At  its  lower  extremity 
the  canal  terminates  in  a  blind  pouch  at  the  round  window, 
the  cascum  vestibuli,  the  basilar  membrane  completely  shut- 
ting it  off  from  the  vestibule.  The  superior  blind  extremity  is 
called  the  lagena.  The  superior  and  inferior  walls  are  formed 
by  a  continuation  of  the  divergent  lips  of  the  osseous  spiral 
lamina,  each  of  which  becomes  membranous  after  the  division 
of  the  bony  partition  into  two  plates,  and  extends  to  the  op- 
posite bony  wall  of  the  cochlea.     The  inferior  membranous 


THK  MEMBRANOUS  COCHLEA.  4I 

wall  or  floor  is  called  the  membrana  basilaris.  At  the  sulcus 
spiralis,  the  basilar  membrane  becomes  much  thickened,  form- 
inii^  the  limbus  laminiv  spiralis,  or  crista  spiralis.  This  separates 
into  two  lips,  the  furrow  thus  formed  beinj;^  called  the  sulcus 
spiralis  internus.  This  groove  is  lined  with  cuboidal  epithe- 
lial cells  which  pass  upward  to  the  vestibular  li{).  The  basilar 
membrane  stretches  from  the  tympanic  lip  of  the  crista  spira- 
lis to  the  spiral  ligament:  it  is  made  up  t)f  tightly  stretched 
transverse  fibres,  the  length  of  the  successive  fibres  increas- 
ing from  the  base  of  the  cochlea  to  the  apex.  The  tvmpanic 
surface  of  the  membrana  basilaris  is  covered  with  jiolvgonal 
pavement  e{)ithelium  continuous  with  the  lining  of  the  scala 
tympani. 

The  epithelium  of  the  ujiper  surlace  ol  the  basilar  mem- 
brane is  cuboidal  for  a  short  distance  beyond  the  sulcus  spi- 
ralis internus;  the  cells  then  become  successively  columnar, 
and  farther  outward  undergo  certain  changes  (to  be  de- 
scribed later),  as  a  result  of  which  there  appears  to  be  a  ridge 
along  the  surface  of  the  basilar  membrane.  Closer  inspection 
shows  that  this  ridge  is  reallv  a  series  of  arches.  Beyond 
this  ridge  the  cells  again  become  cuboidal.  This  kjngitudi- 
nal  ridge,  which  is  continuous  along  the  central  portion  of  the 
basilar  membrane  from  the  round  window  to  the  lagena.  aj)- 
pears  as  a  papilla  in  a  vertical  section  of  the  cochlea,  and  is 
called  the  papilla  acustica  or  zona  tecta  of  the  membrane; 
the  outer  jjoriion  is  called  the  zona  pectinata,  and  the  inner 
the  zona  perforata.  The  epithelium  of  the  zona  perforata  is 
cuboidal  and  pierced  with  nerve  fibres  which  reach  it  by 
passing  outward  from  between  the  lips  of  the  osseous  lamina. 
Where  it  joins  the  zona  tecta  the  cells  become  columnar,  and 
are  called  the  inner  supporting  cells.  Next  to  these  is  a  sin- 
gle row  of  elongated  cells  terminating  above  in  cilia;;  these 
are  the  inner  hair-cells.  Beyond  the  inner  hair-cells  lie  the 
inner  rods  of  Corti,  which  rise  from  the  basilar  membrane, 
and  form,  with  the  outer  fods,  an  arch  called  Corti's  arch. 

This  arch  can  be  plainly  seen  in  microscopic  specimens  (see 
Fig.  24)  when  the  sections  are  made  perpendicular  to  the  basi- 
lar membrane,  since  it  extends  throughout  the  entire  length  of 
the  cochlea.  These  successive  arches  form  a  closed  passage 
or  tunnel  from  the  lowest  portion  of  the  cochlea  to  its  apex, 
covering  over  the  portion  of  the  membrana  basilaris  between 
the  bases  of  the  inner  and  outer  rods.     The  inner  rods  arise 


42        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

from  a  broad  base  and  extend  upward  and  outward  at  an 
angle  of  about  sixty  degrees.  Immediately  above  the  base 
the  cells  become  narrow,  transparent,  and  structureless ;  they 
terminate  in  a  club-shaped  upper  extremity  or  head,  which  is 
hollowed  out  on  its  outer  aspect  for  the  reception  of  a  corre- 
sponding rounded  process  upon  the  outer  rods.  From  the 
head  of  each  inner  rod  a  process  extends  horizontally  inward, 
separating  the  adjacent  hair  cells.  The  outer  rods  are  more 
numerous  than  the  inner,  and  make  an  angle  of  about  forty- 
five  degrees  with  the  basilar  membrane;  they  are  longer  than 
the  inner  rods,  but  of  the  same  shape,  and  their  club-shaped 
heads  fit  into  the  articular  process  upon  the  outer  surface  of 
the  head  of  the  corresponding  inner  rod.  The  outer  cells 
being  greater  in  number  than  the  inner,  each  member  of  the 


Fig.  24. — Vortical  section  of  the  meiiibraiious  cochlea.  (Retzius.)  cs,  Limbus  laminae 
spiralis  ;  wc.  Membrane  of  Corti  ;  si,  Sulcus  internus  ;  is.  Inner  supporting 
cells ;  /V,  Inner  rods  ;  iA,  Inner  hair-cells  ;  a'A^-d/i*,  Outer  hair-cells  ;  ds,  Dei- 
ters's  cells ;  as,  Supporting  cells  of  Hensen  ;  rS,  Nerve  fibres  ;  «'-«*,  r/.  Nerve 
fibres  to  hair-cells  ;  a/,  Nuel's  space  ;  mS,  ml>\  tb.  Basilar  membrane  ;  lis,  Spiral 
ligament. 

latter  series  supports  two  or  three  of  the  external  fibres  of 
Corti.  Beyond  the  outer  rods  there  are  found  from  three 
to  five  rows  of  hair-cells,  of  the  same  general  structure  as 
those  observed  in  the  zona  perforata.  They  rise,  however, 
almost  perpendicularly  from  the  basilar  membrane,  thus  leav- 
ing a  space  between  the  outer  rods  and  the  inner  row  of  hair 
cells,  known  as  Nuel's  space.  The  rows  of  outer  hair-cells 
are  separated  from  each  other  by  the  cells  of  Deiters.  These 
are  broad  at  their  base,  but  narrow  as  they  approach  the  sur- 
face, and  are  marked  along  their  inner  border  by  a  bright 
line  which  runs  the  entire  length  of  the  cell  from  the  upper 
to  the  lower  extremity.  The  upper  extremity  of  this  bright 
line,  called  the  supporting  fibre,  terminates  in  a  delicate 
lamella  or  phalanx;  the  contiguous  phalanges  form  by  their 


THE    MKMHRANK    OF   CORTI.  43 

union  a  reticular  membrane,  throu<;!i  the  interstices  of  which 
the  outer  hair-cells  project.  Beyond  the  cells  of  Deiters  the 
epithelium  again  becomes  columnar,  forming  the  outer  sup- 
porting cells,  beyond  which  it  resumes  gradually  the  form 
found  in  the  zona  pectinata. 

The  membrana  reticularis  is  formed  bv  the  union  of  the 
phalanges  of  the  supporting  fibres  of  Deiters's  cells;  its  outer 
limit  is  poorly  defined.  It  passes  inward  from  the  inner  row 
of  Uciters's  cells  to  the  summit  of  Corti's  arch,  to  which  it  is 
attached. 

The  Meinhrani'  of  Corti,  or  Mcmbraua  Tcctona. — This  is 
a  gelatinous  membrane  arising  from  the  upper  border  of  the 
sulcus  spiralis  internus,  just  below  the  attachment  of  Reissner's 
membrane,  and  extending  outward,  over  the  papilla  acustica. 
beyond  the  outer  row  of  Deiters's  cells;  it  is  intimately  con- 
nected with  the  hair-cells,  but  in  cxactlv  what  manner  is  still 
a  mooted  tjuestion.  The  hair  cells  are  supposed  to  be  the 
specialized  end  organ  of  the  cochlear  nerve;  the  nerve  fibres 
pass  through  the  zona  perforata  as  naked  axis  cylinders,  and 
have  been  traced  bv  Katz  *  to  the  interior  of  the  inner  hair 
cells.  Delicate  fibrillx  also  cross  beneath  the  arch  of  Corti. 
and  have  been  traced  to  the  outer  of  Deiters's  cells  and  to 
the  outer  hair  cells  which  thcv  probablv  enter,  although  this 
is  not  certain. 

Having  describefl  the  peripheral  termination  of  the  au- 
ditorv  nerve,  we  will  next  follow  its  fibres  backward  to  the 
main  trunk. 

From  the  cochlear  hair-cells  the  filaments  pass  inward  be- 
tween the  laversof  the  osseous  spiral  lamina,  resume  their  me- 
duUated  laver,  and  unite  to  form  the  cochlear  branch  of  the 
auditorv  nerve  in  the  tubulus  centralis  modioli.  Where  the 
fibres  of  distribution  radiate  from  the  central  trunk  within  the 
modiolus  a  ganglionic  enlargement  is  found,  called  the  spiral 
ganglit^n.  From  the  crista:  acustica:  and  macula:  acusticae 
the  nerve  filaments  pass  through  minute  foramina  in  the  walls 
of  the  bonv  labvrinth.  The  nerve  filaments  unite  to  form  the 
vestibular  branches  of  the  auditory  nerve,  the  fibres  from  the 
saccule  forming  the  inner  branch,  those  from  the  utricle  and 
ampulla  of  the  external  and  superior  canals  the  superior 
branch,  and  those  from  the  ampulla  of  the  posterior  canal  the 

*  Arch,  fiir  Ohrenheilk.  vol.  xxix,  p.  54. 


44        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

inferior  branch.  These  foramina  constitute  the  macula  cri- 
brosa  of  the  fovea  spherica,  and  fovea  elliptica. 

The  Blood  Supply  of  the  Labyrinth  (Plate  III).— T/ie 
Arteries. — The  blood  supply  is  derived  from  the  internal  audi- 
tory artery,  a  branch  of  the  basilar.  The  artery  accompanies 
the  auditory  nerve  to  the  labyrinth,  where  it  divides  into  two 
branches,  the  one  supplying  the  vestibule  and  semicircular 
canals,  the  other  following  the  cochlear  branch  of  the  nerve  to 
the  cochlea,  where  minute  vessels  pass  outward,  forming  an 
arterial  plexus  for  the  supply  of  the  membranous  cochlea.  The 
minute  vessels  radiate  from  the  larger  arterial  twigs  toward 
the  outer  labyrinthine  walls  of  the  scala  vestibuli  and  scala  ty  m- 
pani,  but  are  most  prominent  in  the  walls  of  the  scala  vestibuli. 

The  Veins. — The  veins  follow  the  same  general  course  as 
the  arteries,  the  smaller  branches  uniting  to  form  three  main 
channels — the  vein  of  the  cochlear  aqueduct,  the  vein  of  the 
aquaeductus  vestibuli,  and  occasionally  a  third  vessel  is  found, 
the  internal  auditory  vein,  although  this  is  the  least  constant 
branch. 

The  vein  of  the  aquseductus  cochleae  passes  through  the 
cochlear  aqueduct  to  the  internal  jugular.  The  vestibular  vein 
joins  the  superior  petrosal  sinus,  leaving  the  labyrinth  through 
the  aquccductus  vestibuli,  while  the  internal  auditory  vein  ac- 
companies the  artery  of  the  same  name  and  empties  into  either 
the  transverse  or  inferior  petrosal  sinus. 

The  terminal  branches  of  the  venous  channels  anastomose 
freely  with  one  another,  forming  spiral  plexuses  or  loops.  In 
general,  it  may  be  said  that  the  blood  current  enters  the  laby- 
rinth upon  one  aspect,  and,  instead  of  forming  a  complete  cir- 
cuit and  finding  an  exit  in  the  same  region,  passes  out  on  the 
opposite  side  of  the  labyrinthine  cavity,  the  chief  avenue  of 
venous  discharge  from  the  cochlea  being  the  vein  of  the  coch- 
lear aqueduct. 

Boettecher*  describes  a  capillary  twig  running  along  the 
tympanic  surface  of  the  basilar  membrane  under  the  arch  of 
Corti,  which  he  calls  the  vas  spirale  of  the  cochlea.  Its  exist- 
ence has  been  denied  byBertholdjfand  Siebenmann.:}:  Eichler* 

*  Arch,  fur  Ohrenheilk,  vol.  xxiv,  p.  i. 

f  Schwartze's  Handb.  der  Ohrenheilk.,  1893,  vol.  i,  p.  711. 
X  Arch,  fiir  Ohrenheilk.,  vol.  xxxv,  p.  115. 

*  Abhandl.  d.  math.  phys.  Klasse  der  k.  sach.  Gesell.  der  Wissenscnaft  des  physi- 
olog.  Inst,  zu  Leipzig,  1892,  vol.  xviii,  No.  5,  p.  311. 


PLATE    HI 


TuK  Vascilar  Supply  of  the  Cochlea.     ^Moditied  from   Hyrtl.) 


THK    AIDITORV    NKKVE.  45 

has  made  important  investigations  upon  this  subject,  from 
which  it  seems  probable  that  the  capillary  spiral  plexus  is 
formed  by  the  cochlear  vessels  both  in  the  sulcus  internus 
and  upon  the  tympanic  surface  of  the  basilar  membrane  be- 
neath the  arch  of  Corti.  The  spiral  plexus  is  particularly 
prominent  in  the  lower  turn  of  the  cochlea.  A  somewhat 
similar  anastomosis  exists  also  in  the  ligamentum  spiralc. 

According  to  Siebenmann's  investigations,  the  internal  au- 
ditory artery  usually  divides  into  three  branches — the  coch- 
lear, vestibular,  and  vestibulo-cochlear — the  particular  por- 
tions supplied  bv  each  branch  being  sufficiently  indicated  by 
their  respective  names.  The  particular  manner  in  which  the 
trunk  divides  is  of  but  small  practical  importance,  but  we 
should  remember  that  the  blood  su{)plv  of  the  lower  turn  of 
the  cochlea  is  much  more  abundant  than  that  of  the  uj'pcr 
portions  of  the  spiral. 

If  a  vertical  section  is  made  through  the  cochlea,  it  w  ill  be 
found  that  the  arterial  trunks  lie  chiellv  in  the  walls  of  the 
scala  vestibuli,  as  already  mentioned,  while  the  venous  chan- 
nels are  mostly  conhneil  to  the  walls  of  the  scala  tympani. 
This  arrangement  is  shown  diagrammaticallv  in  IMate  III, 
from  which  it  will  be  seen  that  the  arterial  capillaries  pass 
into  the  venous  in  the  region  of  the  ligamentum  sj)irale. 

The  Auditory  Nerve  (I'late  I\^). — The  auditory  nerve 
trunk  constitutes  the  portio  mollis  of  the  older  anatomists, 
and  is  given  off  from  the  medulla  at  the  posterior  border  of 
the  pons  Varolii.  It  arises  from  two  roots,  the  lateral  or  an- 
terior, constituting  the  vestibular  nerve,  while  the  internal  or 
posterior  fibres  form  the  cochlear  portion. 

The  Coc/ilear  Nerve. — The  posterior  root,  called  also  the  in- 
ternal, constituting  the  cochlear  nerve,  arises  from  a  large- 
celled  nuclear  mass  in  the  medulla  (the  anterior  or  ventral  nu- 
cleus) and  from  a  smaller  aggregation  of  cells  lying  to  the 
outer  side  of  this,  the  tuberculum  acusticum.  From  the  ven- 
tral nucleus  of  each  side  two  bundles  of  fibres  are  given  off, 
one  of  which  is  of  large  size  and  passes  to  the  olivary  body  of 
the  opposite  side,  the  other,  of  smaller  dimensions,  to  the  olivary 
body  of  the  same  side.  The  crossed  fibres  by  their  decussa- 
tion constitute  the  corpora  trapezoides,  a  name  applied  on  ac- 
count of  the  peculiar  appearance  which  they  give  to  a  section 
of  the  medulla  in  this  region.  From  each  olive  four  sets  of 
fibres  are  given  off.    The  larger  number  pass  to  the  [posterior  of 


46        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

the  corpora  quadrigemina  through  the  fillet,  a  small  bundle 
passes  to  the  spinal  cord,  a  third  passes  to  the  region  of  the 
abducens  nucleus  and  communicates  with  it,  while  a  fourth 
bundle  of  fibres  passes  to  the  cerebrum.  From  the  tubercu- 
lum  acusticum  a  small  bundle  of  fibres  crosses  the  median 
line  to  the  opposite  fillet,  uniting  with  those  which  pass  be- 
tween the  olivary  body  and  the  posterior  of  the  corpora  quad- 
rigemina of  this  side. 

To  recapitulate  briefly,  most  of  the  fibres  from  either 
cochlear  nerve  pass  to  the  opposite  side  of  the  brain  through 
the  trapezoid  bodies  to  the  opposite  olive,  then  through  the 
fillet  to  the  posterior  quadrigeminal  body,  accompanied  by  a 
few  filaments  from  the  tubcrculum  acusticum.  A  small  pro- 
portion of  the  fibres  in  the  cochlear  nerve  in  question  do  not 
cross,  but  pass  to  the  cortical  centres  of  the  corresponding 
side  of  the  brain  through  the  olive  of  this  side.  The  course 
of  the  fibres  from  the  corpora  quadrigemina  has  not  been  defi- 
nitely made  out,  although  the  position  of  the  nuclei  in  the 
medulla  and  the  decussation  of  the  fibres  has  been  verified 
by  physiological  experiment.  After  entering  the  corpora 
quadrigemina  the  fibres  are  supposed  to  pass  to  the  poste- 
rior third  of  the  internal  capsule,  and  from  there  to  the  first 
and  second  temporal  convolutions,  this  being  the  auditory 
centre  in  the  cortex  accordinsr  to  the  most  recent  investiira- 
tions. 

TJic  Vestibular  Nerve. — The  vestibular  nerve  arises  from 
the  internal  or  dorsal  nucleus,  close  to  the  vagus  centre,  but 
superficial  to  this.  Branches  originating  in  this  collection  of 
nerve  cells  cross  the  raphe,  embracing  in  their  course  the 
nucleus  of  the  sixth  nerve  and  pass  to  the  cerebral  cortex, 
although  the  exact  course  which  they  follow  is  undetermined. 
A  large  fasciculus  extends  to  the  cerebellum,  passing  first 
through  the  pons,  then  the  vermis,  and  finally  terminates  in 
the  corresponding  cerebellar  hemisphere  and  in  that  of  the 
opposite  side.  The  dorsal  nucleus  communicates  with  the 
spinal  cord  through  a  fasciculus  which  passes  downward  and 
inward  between  the  olivary  bodies. 

Besides  the  cochlear  and  vestibular  roots,  the  auditory 
trunk  contains  a  bundle  of  fibres  which  emerge  between  the 
roots  already  described.  These  arise  from  an  aggregation  of 
cells,  called  Deiters's  cells,  lying  in  the  medulla  between  the 
anterior  nucleus  and  the  olivary  body.    The  branches  of  com- 


PLATE    IV. 


The  Auditory  Nerve.     (Modified  from  Freud.) 


THK    AUDITORY    NKRVK. 


47 


niunication  with  the  other  nuclei  of  the  eii^lith  nerve  and  with 
other  cerebral  centres  are  undetermined. 

We  thus  appreciate  the  complexity  of  the  central  portion 
of  the  acoustic  apparatus,  and  may  realize  what  manifold 
causes  may  exist  for  impairment  or  perversion  of  function. 
We  must  bear  in  mind  that  anv  disturbance  of  audition  of 
nervous  origin  may  be  variously  located  at  any  point  between 
the  cochlea,  which  represents  the  end  organ  of  the  auditory 
nerve,  and  the  first  and  second  temporal  convolutions  of  the 
cerebrum,  which  represent  the  cortical  auditory  area.  The 
fibres  from  the  cochlea  of  either  side,  according  to  our  descrip- 
tion, pass  through  the  cochlear  nerve  to  the  ventral  nucleus 
and  to  the  tuberculum  acusticum,  most  of  the  fibres  passing 
to  the  superior  olive  of  the  opposite  side  through  the  corpora 
tra[)ezoides,  and  then  to  the  corresponding  posterior  quadri- 
geminal  body  through  the  fillet ;  thence  to  the  posterior  third 
of  the  internal  capsule,  and  thence  to  the  first  and  second 
temporal  convolutions.  A  smaller  collection  of  fibres  from 
the  anterior  or  ventral  nucleus  j)asses  t(j  the  olive  of  the  same 
side,  through  the  trajtezoid  bodv  and  to  the  cortical  area  of 
this  side,  following  a  course  similar  to  that  j)ursued  by  the 
fibres  from  the  opposite  olivary  body;  from  this  olivary 
bodv  otlier  fibres  pass  to  the  cerebellum,  to  the  spinal  cord, 
and  to  the  abducens  nucleus. 

The  portion  of  the  cochlear  nerve  terminating  in  tlie  tuber- 
culum acusticum  sends  a  few  decussating  fibres  to  the  oppo- 
site fillet,  its  only  other  c»)mmunication  being  that  afforded 
by  its  immediate  proximity  to  the  anterior  nucleus. 

The  vestibular  nerve  twigs  amalgamate  into  a  trunk,  which 
terminates  in  the  internal  or  dorsal  nucleus,  from  which  fibres 
pass  to  the  spinal  cord,  to  the  cerebellar  hemisphere  of  the 
same,  and  to  that  of  the  opposite  side,  and  probably  to  the 
opposite  cerebral  hemisphere.  The  communication  with  the 
cerebellum  is  the  most  extensive,  and  this  portion  of  the  brain 
constitutes  the  important  terminus  of  the  vestibular  branch 
of  the  auditory  trunk. 


CHAPTER    II. 

THE   PHYSIOLOGY   OF   THE   EAR. 

In  order  to  understand  the  manner  by  which  sound  per- 
ception is  effected,  it  will  be  well  to  recall  the  physical  prin- 
ciples involved  in  sound  production  and  transmission. 

Sound  is  a  mode  of  motion  produced  by  the  vibration  of 
matter.  Vibrations  are  transmitted  to  the  organ  of  hearing 
through  any  elastic  medium.  If  the  vibrations  succeed  each 
other  at  regular  intervals  and  with  sufficient  rapidity  they 
affect  the  ear  collectively,  rather  than  as  separate  impulses, 
and  produce  what  is  known  as  a  musical  sound.  If  the  im- 
pulses are  irregularly  repeated,  or  if  the  interval  between 
each  is  of  considerable  duration,  the  impression  constitutes 
a  noise,  each  act  of  transmutation  of  energy  into  motion 
producing  an  effect  upon  the  receptive  centres.  When  the 
impulses  follow  each  other  at  a  rate  of  less  than  sixteen  per 
second  they  are  observed  singly  ;  but  if  at  a  greater  rapidity, 
the  sound  becomes  musical  and  continuous.  According  as 
the  rate  of  vibration  is  slow  or  rapid,  the  note  is  of  low  or 
high  pitch,  until  finally  the  vibrations  follow  each  other  so 
rapidly  that  the  ear  no  longer  appreciates  them.  From  this 
we  see  that  the  ear  possesses  certain  limits  of  perception  for 
musical  sounds,  between  which  all  regularl}'^  recurring  vibra- 
tions impress  the  organ  in  a  certain  definite  way.  These 
limits  are  called  the  tone  limits  of  the  ear,  and  range  from 
about  sixteen  double  vibrations  per  second  to  thirty-two  thou- 
sand five  hundred  double  vibrations  per  second. 

It  will  be  understood  that  the  figures  given  represent  the 
average  limits  only,  in  certain  instances  the  lower  limit  being 
somewhat  below  the  one  given,  while  the  upper  limit  may  be 
higher.  Quite  distinct  from  the  pitch  of  a  note  is  its  intensity 
or  loudness;  this  depends  upon  the  amplitude  or  extent  of 
each  individual  vibration.  Although  depending  upon  entirely 
different  physical  conditions,  pitch  and  intensity  are,  to  a  cer- 

(48) 


SOUND. 


49 


tain  extent,  related,  since,  as  the  vibrations  increase  in  num- 
ber, the  space  traversed  during  each  unit  of  time  by  a  vibrat- 
ing body  must  be  less.  We  quite  unconsciously  prove  the 
truth  of  this  statement  when  we  remember  that  we  associate 
loud  sounds  with  high,  shrill  notes,  while  the  reverse  is  true 
of  tones  of  the  lower  portion  of  the  register.  In  other  words 
a  given  force  will  produce  a  more  intense  sound  if  it  acts  ujion 
a  body  in  such  a  manner  as  to  produce  molecular  vibrations 
rather  than  vibrations  c?i  luasse. 

For  convenience  in  rec(jrding  the  various  rates  of  vibration, 
a  tuning  fork,  or  other  sounding  body  making  sixteen  double 
vibrati(jns  per  second  (V.  vS.),  may  be  called  C-' ;  one  making- 
double  this  number  of  vibraticjns  would  be  called  C-' ;  the 
two  notes  diflering  from  each  other  bv  an  octave.  This  divi- 
sion of  the  musical  scale,  should  be  remembered  as  indicating 
that  when  two  musical  notes  differ  from  each  other  bv  an 
octave  the  rates  of  vibration  are  as  two  to  one. 

In  the  above  we  have  considered  simj)Ie  vibrations  onlv  ; 
but  it  is  to  be  remembered  that  a  note  is  seldom  heard  ab- 
solutelv  pure,  but  is  accompanied  bv  tones  of  higher  pitch  in 
the  musical  scale.  These  are  called  overtones,  and  they  mcjdify 
the  character  ol  the  fundamental  note.  These  overtones  give 
the  individualitv  or  qualitv  to  the  various  instruments  used  in 
an  orchestra,  and  enable  us  to  distinguish  whether  a  given  note 
is  sounded  upon  a  wind  or  string  instrument.  These  har- 
monics are  much  more  prominent  in  the  lower  divisions  of 
tlie  scale,  and,  as  will  be  seen  when  we  come  to  speak  of  the 
functional  examination  of  the  ear,  are  to  be  borne  in  mind, 
since  bv  their  perception,  in  [)lacc  of  the  fundamental  tone 
erroneous  deductions  mav  be  drawn. 

Sound  waves  are  proj^agated  in  anv  medium  surrounding 
a  vibrating  bodv  at  rates  varving  with  the  densitv  of  the 
medium.  The  rate  of  transmission  is  greater  in  solids  and 
liquids  than  in  gases.  In  gaseous  media  the  rate  of  trans- 
mission of  sound  is  in  inverse  proportion  to  the  density  of 
the  gas. 

We  are  now  prepared  to  studv  the  action  of  the  transmit- 
ting mechanism  of  the  ear  from  a  physiological  standpoint, 
bearing  in  mind  that  this  portion  of  the  organ  subserves  the 
purpose  simplv  of  conducting  aerial  vibrations  to  the  end  or- 
gan of  the  auditory  nerve,  which  analyzes  them,  so  that  each 
individual  note  produces  certain  specific  effects  upon  the  re- 


50   THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

ceptive  centres.  We  next  consider  the  use  of  the  various 
portions  of  the  conducting  mechanism. 

The  Auricle. — The  auricle,  representing  the  open  end  of  a 
funnel,  collects  aerial  vibrations  and  directs  them  into  the  ex- 
ternal meatus.  Its  angle  of  attachment  to  the  skull  and  the 
variations  in  contour  encountered  in  different  individuals  no 
doubt  exert  slight  influences  upon  sound  perception,  but  this 
fact  may  be  practically  disregarded  in  man,  and  the  auricle 
may  be  removed  without  seriously  interfering  with  the  func- 
tion of  audition.  Among  the  lower  animals  the  auricle  plays 
a  very  important  part  in  the  sense  of  hearing,  being  movable, 
and  capable  of  assuming  various  positions  from  volition  or 
reflex  action  in  order  better  to  collect  aerial  vibrations  from 
different  ])oints. 

The  External  Meatus. — The  external  meatus  constitutes 
a  tube  through  which  the  sonorous  impulses  are  conveyed  in- 
ward toward  the  labyrinth  with  undiminished  intensity.  Even 
if  this  tube  is  very  small  in  its  deep  portion,  the  function  of 
audition  may  be  but  little  impaired,  the  oscillations  in  the 
column  of  air  being  transmitted  with  undiminished  intensity. 
If  the  narrowing  takes  place  at  the  orifice  of  the  meatus, 
acuteness  of  hearing  is  much  diminished.  This  condition  is 
occasionally  found  in  the  aged  in  whom  the  tissues  have  un- 
dergone a  certain  amount  of  atrophy,  resulting  in  the  collapse 
of  the  superior  wall  of  the  cartilaginous  meatus  to  such  an  ex- 
tent that  it  lies  in  contact  with  the  inferior  wall,  completely 
occluding  the  canal.  Occasionally  the  tragus  is  abnormally 
developed,  and  projects  backward  over  the  mouth  of  the 
canal  in  such  a  manner  as  to  offer  an  obstruction  to  the  en- 
trance of  the  sound  waves.  This  condition  also  renders  the 
hearing  less  acute. 

As  mentioned  in  a  previous  chapter,  the  external  auditory 
meatus  is  not  directed  horizontally  inward,  but  the  cartilagi- 
nous and  osseous  portions  join  at  an  obtuse  angle  both  in 
the  horizontal  and  vertical  plane.  The  cartilaginous  canal  is 
directed  upward,  backward,  and  inward,  while  the  osseous 
portion  extends  forward,  downward,  and  inward.  Where  the 
cartilaginous  meatus  joins  the  auricle  the  posterior  wall  pre- 
sents a  deep  fossa  or  depression,  and  the  antero-inferior  wall 
of  the  bony  canal  close  to  the  membrana  tympani  exhibits  a 
somewhat  similar  feature.  In  the  cartilaginous  canal  this 
excavated  portion  acts  with  the  auricle  to  collect  the  waves 


FUNCTION    OF   THK    MEMBRANA    TVMPANI.  51 

of  sound  and  direct  them  into  the  meatus,  while  bv  the  hol- 
lowing out  of  the  antero-inferior  wall  of  the  deeper  portion  of 
the  meatus,  the  surface  presented  is  parabolic,  from  which 
reflected  waves  are  directed  almost  perpendicularly  uj)on  the 
drum  membrane.  Since  the  meatus  is  a  closed  tube  it  neces- 
sarily j)ossesses  a  fundamental  note,  which,  according  to 
Gad,*  lies  in  the  fourth  accentuated  octave,  representing 
about  4,056  V.  S.  The  effect  of  the  resonant  action  of  the 
canal  ujion  audition  is  practically  inappreciable,  its  primary 
note  lying  beyond  the  limit  of  the  conversational  voice.  When, 
however,  the  middle  car  is  filled  with  fluid  or  the  drum  mem- 
brane is  much  thickenetl,  the  rescwiant  action  of  the  canal 
becomes  more  marked  and  is  demonstrable.  This  is  also 
true  when  the  meatus  is  closed  with  tiie  finger  or  occluded 
by  a  foreign  body,  the  imprisoned  column  of  air  under  these 
conditions  being  set  in  vibration  through  the  nudium  of  the 
crani;!)  boms. 

The  Membrana  Tympani. — This  structure  acts  at  once  as 
a  prutecti\e  septum  to  the  parts  hing  within  the  middle  car. 
aiul  as  a  mechanical  device  for  the  recij)tion  (jf  sonorous  vi- 
brations, which  are  then  transmitted  through  the  agency  of 
the  ossicular  cluiiii  to  the  perilymph,  being  brought  into  rela- 
tion with  this  fluid  by  the  foot  plate  of  the  stapes.  The  ad- 
vantage gained  dej)ends  upon  the  relatively  large  surface 
which  the  membrana  tympani  presents  in  comparison  with 
that  of  the  foot  {>late  of  the  stapes.  Any  impluse,  there- 
fore, acting  upon  the  membrane  is  transmitted  to  the  stapes, 
at  which  [>oint  its  power  is  much  augmented.  The  drum 
membrane  is  usually  spoken  of  as  a  tense  fibrous  septum,  and 
hence  should  possess  a  fundamental  note  peculiar  to  itself. 
The  fact  is,  however,  that,  owing  to  the  arrangement  of  the 
radiating  and  circular  fibres  of  the  lamina  propria,  its  mode 
of  attachment  to  the  malleus  handle,  its  oblique  position, 
and  the  relaxed  condition  of  its  upper  portion— the  mem- 
brana flaccida — its  fundamental  note  exercises  but  an  un- 
imjiortant  influence  upon  the  sense  of  hearing.  It  therefore 
transmits  notes,  varying  greatly  in  pitch,  with  equal  facility 
and  without  the  accentuation  of  any  particular  tone,  a  phe- 
nomenon which  would  necesrarily  occur  if  the  membrane 
itself  possessed  a  fundamental  note.     This  impartial  transmis- 

♦Schwartze,  Handb.  der  Ohrenheilk.,  Leipzig,  1S92,  vol.  i,  p.  338. 


52   THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

sion  of  sound  waves  which  impinge  upon  it,  without  reference 
to  their  pitch  depends  chiefiy  upon  the  disposition  of  the  cir- 
cular and  radiating  fibres  in  its  connective-tissue  layer.  The 
circular  fibres  serve  to  obliterate  any  resonant  action  which 
might  result  from  the  radiating  fibres  being  thrown  into  sym- 
pathetic  vibration.  In  the  same  way  the  handle  of  the  malleus 
aids  in  cutting  off  the  overtones,  acting  as  a  load  upon  the  vi- 
brating membrane  and  preventing  the  accentuation  of  any 
harmonic.  The  umbilication  of  this  diaphragm  at  the  umbo 
possesses  a  mechanical  advantage,  a  force  acting  upon  it  being 
increased  in  intensity  as  it  is  transmitted  to  the  malleus  handle, 
while  the  distance  traversed  by  the  manubrium  is  correspond- 
ingly diminished. 

The  Ossicular  Chain. — The  alternate  conditions  of  conden- 
sation and  rarefaction  brought  about  by  a  sounding  body  are 
transmitted  to  the  labyrinthine  structures,  after  impact  against 
the  drum  membrane,  through  the  ossicular  chain.  The  outer 
member  of  this  chain,  the  malleus,  is  attached  to  the  membra- 
na  in  the  manner  already  described,  while  the  innermost  os- 
sicle, the  stapes,  is  in  contact  with  the  labyrinthine  fluid  at 
the  oval  window.  Helmholtz*  has  shown,  from  the  physical 
laws  governing  the  transmission  of  sonorous  vibrations,  as 
the  dimensions  of  the  ossicles  are  so  minute  in  comparison 
with  the  length  of  the  waves  which  they  transmit,  that  they 
may  be  considered  as  acting  cii  masse — that  is,  each  component 
of  the  chain  acts  as  a  single  oscillating  particle  of  infinitesimal 
dimensions,  rather  than  as  a  solid  bodv  the  molecules  of  which 
are  in  a  state  of  vibration.  Viewed  in  this  manner,  we  have 
to  deal  with  a  svstem  of  levers  through  which  a  force  applied 
at  the  tip  of  the  malleus  acts  upon  the  stapes  with  increased 
energy,  but  with  a  corresponding  diminution  in  the  space 
traversed  in  a  unit  of  time.  As  the  result  of  experiment,  the 
same  author  f  found  that  any  force  acting  upon  the  tip  of  the 
manubrium  was  augmented  one  and  a  half  times  at  the  incudo- 
stapedial  articulation,  the  extent  through  which  the  tip  of 
the  long  process  of  the  incus  moved  being  diminished  two 
thirds. 

The  preceding  remarks  regarding  the  lever-like  action  of 
the  ossicles  refers  only  to  forces  tending  to  displace  the  mal- 
leus inward.     It  will  be  remembered  that  in  describing  the 

*  0/>.  cit.,  p.  12.  t  op.  cit.,  p.  46. 


THE    FUNCTION   OF   THE   OSSICLES.  53 

ligaments  of  the  tympanum,  it  was  stated  that  the  anterior 
and  posterior  ligaments  constituted  the  axis  band  of  the  mal- 
leus, this  bone  being  supported  at  their  points  of  insertion 
into  its  neck,  and  rotating  about  an  imaginary  line  passing 
through  these  points  and  the  tympanic  attachments  of  the 
ligaments  as  an  axis.  The  peculiar  structure  of  the  malleo- 
incudal  articulation  must  also  be  borne  in  mind,  the  articular 
surface  of  the  head  of  the  malleus  being  in  contact  with  the 
saddle-shaped  articular  surface  of  the  incus.  This  articular 
surface  is  provided  with  a  toothlike  projection,  so  that  when- 
ever the  manubrium  of  the  malleus  moves  inward,  with  a  con- 
sequent outward  movement  of  the  head,  this  motion  is  trans- 
mitted to  the  incus,  and  bv  this  ossicle  conveved  to  the  stapes. 
If,  however,  the  tip  of  the  manubrium  is  drawn  outward,  the 
toothlike  process  of  the  incus  no  longer  engages  the  mal- 
leus, and  the  articular  surfaces  of  the  ossicles  become  sepa- 
rated. From  this  it  follows  that  the  stai)es  is  but  slightly 
displaced  outward  under  these  conditions.  The  practical 
importance  of  this  will  be  seen  at  once  when  we  remember 
how  frequently  the  tympanic  cavity  is  suddenly  filled  with 
air,  either  bv  accident  or  design,  causing  an  extensive  out- 
ward displacement  of  the  membrana  tvmpani.  If  the  articu- 
lar surfaces  remained  in  contact  under  these  conditions  the 
effect  would  be  to  draw  the  stapes  from  the  oval  win- 
dow. The  long  arm  of  the  lever  above  described  extends 
from  the  tip  of  the  manubrium  to  the  short  process  of  the 
incus,  while  the  point  of  transmission  of  force  to  the  stapes 
lies  in  this  line  at  the  tij>  of  the  long  process  of  the  incus. 
The  relative  lengths  of  these  two  arms  is  in  proportion  of  three 
to  two,  and  the  mechanical  advantage  gained  is  in  the  same 
ratio.  The  movement  of  the  stapes  is  not  directly  inward, 
but  rather  in  an  oblique  plane,  the  ossicle  being  rotated  about 
its  lower  and  posterior  border.  Motion  in  this  oblique  plane 
results  not  onlv  from  the  peculiar  position  of  the  oval  win- 
dow, but  also  from  the  manner  in  which  the  incus  is  fixed  to 
the  tvmpanic  wall,  an  inward  excursion  of  the  malleus  carry- 
ing the  long  process  upward  and  inward  at  the  same  time. 
The  obliquitv  of  the  plane  in  which  the  ossicles  are  placed 
causes  a  slight  movement  forward  in  addition  to  the  dis- 
placement described,  the  resultant  motion  imparted  to  the 
stapes  being  a  rotation  about  its  posterior  and  inferior  bor- 
ders.    The  capsular  ligament  of  the  malleo-incudal  articula- 


54   THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

tion  plays  an  important  part  in  the  proper  performance  of 
the  function  of  this  joint.  If  this  ligament  is  relaxed,  the 
articular  surface  of  the  malleus,  instead  of  being  held  closely 
against  the  corresponding  surface  of  the  incus  and  engaging 
the  tooth-shaped  process  of  the  articular  facet,  is  drawn 
away  from  the  saddle-shaped  articular  surface  of  the  incus, 
and  causes  but  slight  movement  of  the  ossicle.  This  condi- 
tion would  interfere  particularly  with  the  transmission  of 
those  notes,  the  wave  length  of  which  was  relatively  con- 
siderable— in  other  words,  the  lower  notes  of  the  register. 
Too  great  tension  of  the  capsular  ligament  interferes  with 
free  oscillation  of  the  ossicular  chain,  and  consequently  with 
the  proper  transmission  of  sound  waves,  particularly  those 
of  low  pitch.  High  notes,  demanding  but  little  displacement 
of  the  transmitting  mechanism,  are  relatively  less  interfered 
with  by  anomalies  in  the  tension  of  the  tympanic  ligaments. 

It  is  interesting  to  note  here  the  experiments  of  Politzer* 
regarding  the  effect  produced  by  notes  of  various  pitch 
upon  the  excursions  of  the  ossicular  chain.  It  was  demon- 
strated that  the  oscillations  of  the  ossicles  were  less  extensive 
for  very  low  notes  than  for  those  of  the  middle  portion  of 
the  scale.  When  the  pitch  was  very  high,  however,  the  am- 
plitude of  the  ossicular  vibrations  was  again  diminished.  The 
weighting  of  the  ossicular  chain  interfered  with  the  trans- 
mission of  low-pitched  sounds,  while  the  higher  ones  were 
transmitted  practically  without  interference.  As  stated 
above,  although  pitch  depends  upon  the  rate  of  vibration 
and  intensity  upon  the  extent  of  each  oscillation,  a  certain 
relation  must  exist  between  them,  as  is  proved  by  the  well- 
known  fact  to  which  Gad  +  calls  attention — that  of  two  notes 
sounded  with  the  same  intensity,  the  higher  will  seem  the 
louder.  The  importance  of  these  circumstances  can  not  be 
overestimated  in  their  bearing  upon  pathological  conditions 
of  the  conducting  apparatus,  since  the  result  of  clinical  ob- 
servation agrees  with  that  of  physiological  experiment,  show- 
ing that  in  affections  of  the  transmitting  mechanism  alone, 
the  impairment  of  function  occurs  first  for  sounds  of  very 
low  pitch,  the  upper  notes  being  transmitted,  with  a  fair  de- 
jrree  of  accuracy. 


*  Arcliiv  fvir  Ohrenheilk.,  vol.  vi.  p.  35. 

f  Schwartze,  Handb.  der  Ohren.,  Leipzig,  1892,  vol.  i,  p.  336. 


THE    FUNCTION    OF   THF.    MUSCLES.  55 

The  Tympanic  Muscles. — We  have  considered  above  the 
part  plaved  by  the  ossicles  alone,  without  rey^ard  to  tiie  ac- 
tion of  any  muscles  which  miii^^ht  modify  their  response  to 
aerial  vibrations.  It  is  necessarv.  however,  to  bear  in  mind 
that,  in  addition  to  their  ligamentous  supports,  their  action 
is  modified  by  two  muscles — the  tensor  tympani  and  the 
stapedius.  The  anatomical  characteristics  of  these  have  al- 
readv  been  described. 

The  tensor  tympani  muscle,  actin*::^  alone,  would  tend  to 
draw  the  ossicles  inward  and  upward,  crowding  their  articu- 
lar surfaces  together  and  forcing  the  foot  plate  of  the  stapes 
into  the  oval  window.  This  displacement  would  of  necessity 
render  the  membrana  tympani  more  tense;  hence  the  name 
of  the  muscle,  although  its  action  in  this  direction  is  of  but 
little  practical  importance. 

The  action  of  the  stapedius  is  antagonistic  to  that  of  the 
muscle  just  described,  since  by  its  contraction  the  stapes  is 
drawn  out  of  the  oval  windt)w  by  rotating  upon  the  posterior 
margin  of  the  foot  plate,  with  the  effect  of  reducing  the  ten- 
sion of  the  labvrinthine  fluid.  It  is  probable  that  one  of  the 
chief  uses  of  these  muscles  is  to  protect  the  labvrinth  from 
the  injurious  effects  of  loud  sounds,  or  of  the  sudden  conden- 
sation of  air  in  the  meatus  from  anv  cause.  Since  thev  act  in 
opposite  directions,  they  increase  the  elasticity  of  the  ossicu- 
lar chain,  the  one  guarding  the  labyrinth  from  sudden  pres- 
sure from  without,  while  the  other,  bv  crowding  the  ossicula 
together,  militates  against  any  outward  displacement  of  the 
ossicles  from  anv  increase  in  intratympanic  pressure.  One 
value  of  this  action  is  to  guard  the  capsular  ligament  of 
the  malleo-incudal  articulation,  the  fibres  of  which  would 
soon  become  stretched  bv  repeated  condensations  of  air  in 
the  tympanic  cavitv  if  it  were  compelled  to  sustain  the  entire 
pressure. 

The  Muscles  of  the  Eustachian  Tube. — In  order  that  the 
membrana  tvmpani  mav  act  simply  as  a  transmitter  and  col- 
lector of  aerial  vibrations  of  various  lengths,  it  is  essential 
that  its  normal  tension  shall  not  be  interfered  with.  An  abso- 
lutely constant  tension  of  this  membrane  can  exist  only  when 
the  atmospheric  pressure  is  the  same  on  either  side.  To  pre- 
serve this  equilibrium,  the  cavity  of  the  tympanum,  under  nor- 
mal conditions  communicates  freely  with  the  outer  world 
through  the  Eustachian  tube.     Owing  to  the  fact  that  the  an- 


56        THE    ANATOMY    AND    PHYSIOLOGY   OF    THE   EAR. 

terior  and  inferior  walls  of  the  membranous  portion  of  the 
passage  are  formed  almost  entirely  of  fibrous  tissue,  the  an- 
tero-posterior  walls  are  in  contact,  except  along  the  roof,  where 
the  patency  is  preserved  by  the  hook-shaped  process  of  the 
cartilaginous  plate.  Although  the  physical  conditions  admit 
of  the  canal  remaining  patent  in  this  situation,  it  is  probable 
that  the  mucous  membrane  lining  the  passage  is  so  loosely  ap- 
plied, that  even  here  the  lumen  is  practically  obliterated 
when  the  parts  are  at  rest,  but  that  slight  changes  in  pressure 
suffice  to  render  the  tube  permeable  in  this  portion.  This  is 
particularly  true  if  the  intratympanic  pressure  is  increased, 
as  air  passes  more  easily  from  the  tympanum  through  the 
tube  than  in  the  opposite  direction.  It  is  comparatively  un- 
important whether  in  certain  chses  the  canal  is  patent  while 
the  parts  are  at  rest.  Since  the  aeration  of  the  tympanum  is 
accomplished  through  the  action  of  its  attached  muscles,  the 
part  played  by  them  in  audition  is  one  of  great  importance. 
It  will  be  remembered  that  the  tensor  palati  and  the  levator 
palati  are  in  relation  with  the  fibro-cartilaginous  portion  of  the 
Eustachian  passage,  the  former  arising  in  part  from  its  ante- 
rior wall,  while  the  latter  passes  beneath  the  membranous  floor 
along  the  inferior  border  of  the  posterior  cartilaginous  wall. 
Contraction  of  these  muscles  increases  the  caliber  of  the  tube, 
the  tensor  drawing  the  anterior  wall  and  the  cartilaginous 
hook  forward,  while  the  belly  of  the  levator  is  augmented  in 
volume  during  contraction  and  presses  the  inferior  and  pos- 
terior walls  upward,  diminishing  the  diameter  of  the  canal 
from  above  downward,  but  making  it  more  patent.  As  both  of 
these  muscles  are  brought  into  plav  during  the  act  of  deglu- 
tition, the  removal  of  the  air  within  the  middle  ear  must  of 
necessitv  take  place  so  frequently  that  the  equilibrium  of  the 
membrana  tympani  is  not  disturbed.  Temporary  variations 
in  pressure  are  undoubtedly  compensated  for  by  the  action  of 
the  stapedius  and  tensor  tvmj)ani  muscles.  When,  owing  to 
atrophy  of  the  tubal  muscles  or  to  obstruction  of  the  lumen  of 
the  canal  from  swelling  of  the  lining  membrane  or  from  the 
presence  of  secretion,  the  passage  remains  closed  for  a  con- 
siderable period,  rarefaction  of  the  air  within  the  tympanum 
is  the  result.  This  is  brought  about  by  the  absorption  of  air 
into  the  blood  circulating  in  the  lining  membrane  of  the  mid- 
dle ear,  and  by  the  greater  facility  with  which  the  air  passes 
from  the  tympanum  than  in  the  opposite  direction.     This  re- 


THE    FL'NCTION   OF   THE    COCHLEA.  57 

duction  in  pressure  within  the  middle  ear  allows  the  nicm- 
brana  tvmpani  and  attached  ossicular  chain  to  be  forced  in- 
ward by  the  pressure  of  the  atmosphere,  crowding  the  stapes 
into  the  oval  window. 

The  Labyrinth. — The  physiology  of  the  labyrinth  divides 
itself  into  an  investigation  of  the  function  of  the  vestibule,  the 
cochlea  and  the  semicircular  canals. 

The  Cochlea. — The  cochlea  is  that  part  of  the  internal  ear 
specialized  for  the  analysis  of  sonorous  vibrations.  Through 
its  agency  each  component  of  any  complex  sound  affects  one 
portion  of  the  terminal  fibres  of  the  auditory  nerve.  These 
various  stimuli  are  again  combined  in  the  higher  nerve  centres, 
and  are  interpreted  as  characteristic  of  some  particular  vibrat- 
ing body,  and  hence  from  education  enable  us  to  judge  of  the 
conditions  under  which  they  were  produced.  To  effect  this 
separation  of  thecomjjlex  aerial  vibrations  the  undulations  are 
transmitted  by  the  conducting  mechanism  to  a  column  of  fluid, 
the  perilymph.  Recollecting  the  anatomy  of  the  parts,  it  will 
be  remembered  that  the  C(jchlcar  ])erilymphatic  space  is  di- 
vided into  two  channels  lying  one  above  the  other,  communi- 
cating at  the  apex  of  the  spiral  by  a  narrow  passage,  the  heli- 
cotrema,  and  se()arated  from  each  other  by  a  septum  which  is 
partially  osseous  and  in  part  membranous.  The  membranous 
portion  incloses  between  its  two  layers  a  channel,  triangular 
on  cross-section,  the  membranous  cochlea.  This  canal  is  an 
elongated  blind  pouch,  and  is  filled  with  cndolymph  in  which 
float  the  ultimate  fibres  of  the  auditory  nerve. 

The  upi)cr  cochlear  canal  communicates  with  the  vestibule, 
while  the  lower  is  shut  of!  from  the  middle  ear  by  the  mem- 
brane of  the  round  window.  The  membranous  cochlea  termi- 
nates at  its  superior  extremity  as  a  blind  sac,  while  below  it 
joins  the  saccule.  The  floor  of  this  membranous  tube  begins 
at  the  upper  part  of  the  round  window.  The  perilymphatic 
space  through  the  aqueductus  cochlea:  communicates  with 
the  subarachnoid  lymph  space,  while  the  endolymphatic  chan- 
nel, through  the  aqueductus  vestibuli,  opens  into  a  sac  be- 
tween the  layers  of  the  dura  mater.  The  probability  of  the 
communication  between  thisdural  pouch  and  the  lymph  chan- 
nels of  the  dura  has  already  been  discussed. 

Aerial  vibrations  communicated  to  the  stapes  produce  a  f^uid 
wave  in  the  perilymph,  each  inward  excursion  of  the  ossicle 
pushing  the  column  of  fluid  before  it  through  the  scala  ves- 


5$        THE    ANATOxMY   AND    PHYSIOLOGY   OF   THE    EAR. 

tibuli,  thence  through  the  helicotrema,  and  finally  through  the 
scala  tympani  to  the  round  window,  the  membrane  of  which 
is  pushed  outward  into  the  tympanum  to  compensate  for  the 
inward  motion  at  the  vestibular  opening.  Since  the  labyrin- 
thine walls  are  rigid  in  every  other  situation,  and  from  the 
well-known  phvsical  law  that  fluids  are  incompressible,  this 
motion  of  the  perilymph  is  impossible  unless  the  membrane 
of  the  fenestra  rotunda  is  elastic.  The  elastic  partition  sepa- 
rating these  two  channels  modifies  to  an  extent  the  course 
taken  by  this  wave  in  the  perilymphatic  fluid.  This  septum, 
consisting  of  two  layers,  the  space  between  being  filled  with 
fluid  of  the  same  density  as  the  perilymph,  permits  of  the 
transmission  of  the  wave  motion  from  the  upper  to  the 
lower  channel  without  necessitating  its  passage  through  the 
helicotrema.  It  is  evident  that  the  structures  within  the 
membranous  cochlea  must  suffer  some  disturbance  of  equi- 
librium from  the  passage  of  this  fluid  wave.  An  impulse 
causing  the  inward  motion  of  the  stapes  is  communicated 
to  the  perilymph,  which  in  turn  exerts  a  pressure  upon  the 
basilar  membrane;  this  elastic  septum  yields  to  the  pressure 
in  localities  varying  according  to  the  pitch  (or  rate  of  vibra- 
tion) of  the  particular  note  sounded.  The  depression  of  the 
basilar  membrane  at  anv  given  point  causes  a  change  in 
position  in  the  structures  resting  upon  it:  these,  it  will  be 
remembered,  are  the  hair-cells  and  the  rods  of  Corti.  It  is 
probable  that  the  hair-cells,  bv  the  friction  of  their  ciliarv  pro- 
cesses against  the  reticular  membrane  or  against  the  rods  of 
Corti,  transmit  these  impulses  through  the  nerve  filaments 
which  they  contain,  to  the  receptive  centres  of  the  brain. 
Since  the  endolymph  and  perilymph  are  under  equal  pressure, 
a  fact  which  has  been  proved  by  the  investigations  of  Ost- 
mann,*  it  follows  that  all  vibrations  of  the  perilymph  will  not 
pass  the  entire  length  of  the  scala  vestibuli  and  through  the 
helicotrema  before  exciting  similar  waves  in  the  fluid  of  the 
scala  tympani,  but  will  pass  directly  through  the  two  layers 
of  the  membranous  spiral  lamina  at  any  point  where  the  resist- 
ance is  less  than  that  which  must  be  overcome  by  the  passage 
of  the  wave  through  the  helicotrema.  The  fact  that  the  di- 
ameter of  this  communicating  channel  is  much  less  than  that 
of  either  the  scala  vestibuli  or  the  scala  tympani  increases  the 

*  Arch,  fiir  Ohrenheilk,  vol.  xxxiv,  p.  35. 


THE    FUN'CTIOX    OF   THE    COCHLEA. 


59 


resistance  in  this  direction  and  favors  the  passage  of  the  wave 
through  the  elastic  septum  dividing  the  scalee.  The  inferior 
lamella  of  this  partition  is  the  membrana  basilaris,  a  tissue 
calculated  from  its  structure  to  be  easily  affected  by  changes 
in  pressure.  Investigation  shows  that  the  parallel  fibres  of 
the  membrane  are  shortest  in  the  lowest  part  of  the  canal, 
and  gradually  increase  in  length  as  the  spiral  ascends.  The 
shorter  fibres  at  the  base  of  the  cochlea  will  yield  to  the  pres- 
sure caused  by  vibrations  of  short  wave  length,  or  those  con- 
cerned in  the  production  of  the  highest  notes  of  the  scale, 
while  the  slower  oscillations  of  the  low  notes  will  travel 
toward  the  apex  of  the  cochlea  before  displacing  the  basilar 
membrane.  Anatomical  structure  and  phvsical  laws  render 
it  probable,  therefore,  that  the  lowest  turn  of  the  cochlea  is 
concerned  in  the  perception  of  the  high  notes  of  the  scale, 
while  the  upper  turns  serve  for  the  recognition  of  the  deeper 
sounds.  These  deductions  have  been  confirmed  by  the  j)hys- 
i(jlogical  experiments  of  Baginskv.* 

It  seems  probable  that  the  basilar  membrane  is  the  portion 
of  the  auditorv  ajiparatus  designed  for  the  analysis  and  per- 
ception of  musical  notes  as  originallv  suggested  by  Hen- 
sen,  and  that  tlie  rods  of  Corti  are  not  dircctlv  concerned  in 
this  process,  as  Helmholtz  at  hrst  believed. 

It  is  quite  probable  that  these  rods  serve  to  damp  the  vibra- 
tions of  the  membrana  basilaris,  and  to  restrict  them  to  limited 
portions  for  individual  notes.  The  fibres  of  the  basilar  mem- 
brane varv  in  length  from  .041  millimetre  at  the  base  of  the 
cochlea,  t(j  .495  millimetre  at  the  apex.  In  number  they  vary 
from  13,000  to  20,000.  It  is  evident,  therefore,  that  the  per- 
ception of  the  slightest  variation  in  the  rates  of  vibration  can 
theoretically  be  perceived  ;  practically,  differences  of  one  sixty- 
fourth  of  a  tone  can  be  recognized  bv  the  trained  ear  ;  in  the 
higher  registers,  differences  of  half  a  vibration  per  second  can 
be  distinguished  by  skilled  musicians. 

Nothing  has  been  said  in  the  preceding  pages  about  the 
influence  exerted  upon  the  transmission  of  fluid  waves  by  the 
communication  between  the  endolymphatic  and  perilym- 
phatic channels  and  the  intracranial  lymph  spaces.  It  is 
probable  that,  owing  to  the  small  calibre  of  the  communicat- 
ing canals,  the  friction  of  the  fluid  is  so  great  that  their  pres- 

*  Arch,  fiir  Ohrenheilk,  vol.  xxiv,  p.  54. 


6o        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

ence  is  no  protection  against  a  sudden  increase  in  tension 
of  the  lab3'rinthine  fluid,  sudden  augmentation  in  pressure 
being  compensated  for  by  the  elastic  septum  covering  the 
round  window.  When,  however,  the  increase  in  pressure 
within  the  labyrinth  is  very  slow,  such  as  would  result  from  a 
chronic  process  within  the  middle  ear  with  the  production  of 
new  connective-tissue  elements,  crowding  the  stapes  slowly 
into  the  oval  window,  it  is  probable  that  the  equilibrium  of 
the  labvrinthine  fluid  would  be  preserved,  in  part  at  least,  by 
its  passage  into  the  intracranial  lymph  spaces. 

The  perception  of  musical  notes  bv  the  agency  of  the 
cochlea  has  been  considered  first  on  account  of  its  complex- 
itv  ;  but  it  must  be  remembered  that  the  maculre  of  the  sac- 
cule and  utricle  and  the  crista^  of  the  ampullcC  also  contain  the 
terminal  filaments  of  the  eighth  nerve.  It  is  probable  that 
noises  and  perhaps  also  certain  musical  sounds  are  perceived 
here.  It  would  also  seem  that  these  structures  are  particularly 
designed  for  the  reception  of  vibrations  of  great  amplitude, 
which  are  interpreted  as  sound,  but  that  complex  sounds  are 
not  fullv  analvzed  here,  although  certain  variations  in  pitch 
are  recognized.  The  otoliths  are  found  here  and  prevent  too 
extensive  excursions  of  the  ciline  ;  their  presence  in  these 
regions  alone  rather  adds  weight  to  the  theory  that  this  por- 
tion of  the  labyrinth  is  designed  for  the  reception  of  vibrations 
of  considerable  amplitude,  whether  occurring  as  musical  notes 
or  following  each  other  irregularly,  giving  the  impression  of 
a  noise.  It  seems  certain  that  the  ultimate  analysis  of  musical 
tones  can  only  take  place  in  the  cochlea ;  and  hence,  from  the 
anatomical  structure  of  the  parts,  the  musical  notes  whose 
perception  would  be  first  interfered  witii  in  anv  involvement 
of  the  labyrinth  following  a  pathological  process  within  the 
tympanum  should  be  those  perceived  by  the  basilar  mem- 
brane at  the  lowest  part  of  the  cochlea,  or  that  portion  close 
to  the  tympanum.  Clinical  experience  supports  this  view, 
since  in  secondary  labyrinthine  affections  we  find  that  de- 
fective perception  for  the  highest  notes  of  the  scale  is  an  early 
symptom. 

The  Semicircular  Canals. — From  experiments  upon  ani- 
mals and  from  clinical  observations  it  is  supposed  that  the 
semicircular  canals  are  concerned  in  maintaining  the  ecjuilib- 
rium  of  the  body,  and  in  recognizing  any  departure  from  this 
condition.     How  much  this  function  contributes  to  the  abil- 


EFFFXT  OF  TYMPANIC  CHANGES  UPON  THK  LABYRINTH.   6l 

ity  to  judge  of  the  location  from  which  a  given  sound  comes 
can  not  be  determined,  but  it  is  probable  that  the  position 
which  the  head  assumes,  in  order  that  the  ear  may  receive 
the  maximum  impression  of  the  sounding  body,  conveys 
to  the  perceptive  centre,  through  the  agency  of  the  semicir- 
cular canals,  a  certain  stimulus  which  enables  the  listener  to 
locate  the  approximate  position  of  the  sounding  body.  Re- 
cently Ewald  *  has  attributed  to  the  semicircular  canals  the 
power  of  interpreting  a  sixth  special  sense,  which  he  denomi- 
nates as  the  muscular  sense  or  muscle-tonus,  holding  that  the 
perception  and  maintenance  of  stable  equilibrium  are  regu- 
lated by  the  semicircular  canals  through  this  special  sense. 
Such  a  claim  is  difficult  to  controvert.  Any  change  in  muscle- 
tonus  must  disturb  the  equilibrium  of  the  body  to  a  certain 
degree,  and  this  in  turn  would  depend  for  its  appreciation 
upon  the  integrity  of  the  semicircular  canals.  That  these 
portions  of  the  internal  ear  are  the  perceptive  organs  of  the 
sixth  special  sense  has  not.  I  think,  been  conclusivclv  proved. 
The  Effect  of  Changes  within  the  Middle  Ear  upon  the 
Labyrinth. — Since  the  labyrinthine  lluid  is  separated  from  the 
tvin[>aiiic  cavitv  bv  an  elastic  membrane  at  the  round  window 
and  at  the  oval  window  bv  a  movable  osseous  septum,  the 
foot-plate  of  the  sta|)es,  it  follows  that  changes  in  the  tension 
of  the  ossicular  chain,  due  U)  relaxation  or  contraction  of  the 
elastic  structures  within  the  middle  car,  must  cause  variations 
of  pressure  in  the  labvrinlhine  fluid.  Shortening  of  the  os- 
sicular ligaments  and  of  the  tensor  tympani  muscle  will  effect 
this  change  ;  or  the  same  result  might  be  brought  about  by  a 
rarefaction  of  the  air  within  the  tympanum,  the  tension  then 
being  increased  by  the  atmospheric  pressure  without.  Any 
force  acting  to  displace  the  foot-plate  of  the  stapes  inward, 
causes  a  similar  displacement  of  the  labyrinthine  fluid  and  an 
outward  excursion  of  the  membrane  at  the  round  window,  the 
extent  to  which  this  membrane  is  moved  outward  depending 
upon  its  elasticity.  Any  sudden  increase  in  pressure  must  be 
coinpensated  for  by  a  corresponding  displacement  of  this 
elastic  lamella,  since  the  frictit)n  of  the  fluid  against  the  walls 
of  the  narrow  aqueductus  vestibuli  and  aqueductus  cochlea; 
would  prevent  an  outward  flow  in  this  direction.  If  the  pres- 
sure was  maintained  for  a  considerable  time,  a  gradual  outflow 

*  Physiolog.  Untersuch.  Ubcr  dcr  Endorg.  des  Nerv.  Octavus.    Wiesbaden,  1892. 


62        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

of  fluid  through  these  channels  would  undoubtedly  take  place, 
and  the  equilibrium  would  be  restored. 

Bezold  *  has  shown  that  the  excursions  of  the  membrane 
of  the  round  window  are  four  times  as  extensive  as  those  of 
the  foot-plate  of  the  stapes,  in  response  to  any  given  force  dis- 
placing the  latter  inward.  The  area  of  the  stapedial  foot-plate 
is  greater  than  that  of  the  membrana  tympani  secondaria,  and 
hence  displacements  of  this  latter  structure  must  be  corre- 
spondingly more  extensive. 

When  we  come  to  consider  the  effect  of  condensation  and 
rarefaction  of  the  air  in  the  tympanic  cavity  upon  the  tension 
of  the  labyrinthine  fluid,  the  mechanism  of  the  malleo-incudal 
articulation  must  be  borne  in  mind.  The  effect  of  increased 
aerial  pressure  within  the  tympanic  cavity  would  naturally  be 
to  force  the  drum  membrane  outward.  This  outward  move- 
ment would  be  participated  in  by  the  malleus,  and  through 
its  articulation  with  the  incus  would  be  communicated  to  this 
ossicle,  which  in  turn  would  cause  an  outward  movement  of 
the  stapes,  with  a  reduction  of  the  pressure  within  the  laby- 
rintii.  From  the  peculiar  construction  of  the  malleo-incudal 
joint,  very  extensive  outward  excursions  of  the  manubrium 
cause  a  separation  of  the  articular  surfaces  of  the  ossicle,  and 
the  stapes  is  displaced  outward  to  a  comparatively  slight  de- 
gree as  compared  with  the  excursion  of  the  membrana  tym- 
pani. The  membrana  tympani  has  but  little  elasticity,  owing 
to  the  peculiar  structure  of  the  lamina  propria,  and  after  the 
maximum  outward  displacement  has  taken  place  it  forms  a 
rigid  wall.  Beyond  this,  any  increased  pressure  within  the 
tympanum,  due  to  the  introduction  either  of  air  or  fluid, 
causes  an  augmentation  of  labyrinthine  tension,  the  cavity  be- 
ing closed  on  all  sides  by  rigid  walls,  with  the  exception  of 
those  portions  of  the  inner  walls  occupied  by  the  oval  and 
round  windows.  This  increased  pressure  acts  upon  both  the 
foot-plate  of  the  stapes  and  the  membrana  tympani  secondaria, 
since  they  constitute  the  areas  of  least  resistance,  and  their 
inward  displacement  is  opposed  only  by  the  normal  tension 
of  the  labyrinthine  fluid,  which  is  slightly  less  than  that  of  the 
normal  atmospheric  pressure.  When  the  pressure  within  the 
tympanum  is  increased  by  artificial  means,  or  as  the  result  of 
pathological  processes,  and  the  cavity  has  attained  its  great- 


♦  Politzer,  Lehrbuch  dcr  Ohrenheilk.,  \Vien,  1S93,  p.  54, 


EFKFXT  OF  TYMPANIC  CHANGES  UPON  THE  LABYRINTH.  63 

est  dinicnsions  bv  tlie  maximum  displacement  of  tlie  mcm- 
brana  tympani  outward,  the  next  result  is  a  displacement  of 
the  membrana  tympani  secondaria  and  of  the  foot-plate  ot  the 
stai)es  inward,  increasing  the  tension  of  the  perilymph.  The 
movement  of  the  stapes  toward  the  vestibule  is  permitted  bv 
the  separation  of  the  articular  surfaces  of  the  malleus  and 
incus.  The  changes  in  the  endolvmphatic  pressure  are  the 
same  as  those  in  the  perilymph.  This  explains  the  phenom- 
enon observed  frequently  after  over-inflation  of  the  tvm- 
panum,  functional  examination  indicating  increased  labv- 
rinthine  tension  in  spite  of  the  fact  that  the  membrana  tvm- 
pani  has  been  restored  to  its  normal  position. 

Politzer*  has  shown  from  experiments  that  aspiration  of 
the  tympanum — that  is.  artificially  diminishing  the  aerial 
[ircssure  within  it — lowers  the  labyrinthine  pressure  instead 
of  increasing  it.  We  might  suppose  at  first  that  this  latter 
condition  would  result  on  account  of  the  inward  displace- 
ment of  the  ossicular  chain  from  the  pressure  of  the  atmos- 
phere. This  diminution  of  labvrinthine  tension  following 
aspiration  of  the  tvmpanum  is  caused  bv  the  reduction  in  pres- 
sure over  both  the  oval  and  round  windows,  which  more  than 
compensates  for  the  inward  displacement  of  the  stapes  bv  the 
atmospheric  pressure  froiu  without.  In  Polilzer's  experi- 
ments the  i^ressure  within  the  labvrinth  was  equal  to  the 
pressure  of  the  atmosphere,  while  during  life  we  know  that 
it  is  slightlv  less  than  this,  and  in  this  condition  a  moderate 
reduction  ui  tension  in  the  intratympanic  air  would  lower 
labyrinthine  tension  considerably.  As  soon  as  the  pressure 
in  the  middle  ear  is  greatlv  reduced,  labyrinthine  tension  must 
increase  iium  the  extensive  inward  excursion  of  the  stapes. 
The  truth  of  these  conclusions  is  demonstrated  by  the  effect 
of  aspiration  and  auto-inflation  upon  the  perception  of  sounds 
of  dilTerent  pitch,  as  well  as  the  influence  which  these  pro- 
cedures exert  upon  the  conduction  of  sound  through  the  solid 
media  of  the  skull.  It  has  been  proved  by  Bezold  and  Sieben- 
mann  t  that  a  sudden  increase  in  labvrinthine  pressure  renders 
the  perception  of  high  notes  more  keen,  and  increases  bone- 
conduction  as  a  rule.  The  over-inflation  of  the  tympanum  has 
been  found  bv  the  same  investigators  to  efTect  similar  changes. 
Aspiration  of  the  middle  ear,  on  the  other  hand,  according  to 

*  0/>.  lit.,  p.  54.  f  Arch,  of  Otol.,  vol.  xxii,  p.  I. 


64        THE    ANATOMY   AND    PHYSIOLOGY   OF   THE   EAR. 

Siebenmann,*  usually  diminishes  bone-conduction — a  result 
which  we  should  expect  from  the  reduction  of  labyrinthine 
pressure.  The  power  of  hearing  high  notes  is  not  particu- 
larly affected  by  this  procedure,  on  account  of  the  short  wave- 
lengths of  such  sounds  and  the  proximity  of  the  area  to  the 
middle  ear  of  the  cochlea  specialized  for  their  reception.  If 
the  perception  of  high  notes  is  at  all  affected,  it  is  rendered 
less  keen. 

Increased  tension  within  the  labyrinth  from  displacements 
of  the  ossicular  chain  inward — a  condition  which  may  be 
brought  about  from  a  shortening  of  the  muscular  or  liga- 
mentous structures  attached — is  corrected,  up  to  a  certain 
point,  b}'  a  displacement  of  the  membrana  tympani  secondaria 
in  the  opposite  direction.  When  the  limit  of  its  elasticity  is 
reached,  the  perilymph  can  no  longer  vibrate.  Up  to  this 
point,  however,  the  entrance  of  sound  waves  into  the  laby- 
rinth is  not  prevented.  Under  certain  pathological  condi- 
tions the  membrane  of  the  round  window  becomes  thickened 
and  loses  its  elasticity.  When  this  (occurs  even  a  moderate 
displacement  of  the  stapes  inward  may  be  sufficient  to  render 
vibration  of  the  labyrinthine  fluid  impossible.  This  rigidity 
at  the  round  window  exerts  a  greater  influence  when  sudden 
changes  in  labyrinthine  tension  occur  from  extensive  and 
sudden  displacement  of  the  membrana  tympani  and  ossicular 
chain  inward,  than  where  these  changes  come  on  gradually. 
When  the  pressure  is  slowly  increased,  a  compensatory  outflow 
of  the  labyrinthine  fluid  thi-ough  the  channels  of  communica- 
tion with  the  intracranial  lymph  spaces  is  possible;  but  sud- 
den augmentation  of  tension  can  not  be  relieved  in  this  way, 
on  account  of  the  friction  of  the  column  of  fluid  against  the 
walls  of  the  capillary  passages  through  which  it  is  forced. 
This  explains  w'hy  we  find  so  great  a  reduction  of  the  upper 
tone-limit  in  sudden  closure  of  the  Eustachian  tube,  while 
proliferative  changes  within  the  middle  ear  cause  secondary 
labyrinthine  involvement  only  after  a  long  period — in  the  one 
case,  pressure  being  increased  suddenly,  in  the  other  case, 
gradually. 

The  individual  parts  of  the  auditorv  tract  having  been 
considered,  a  few  words  may  not  be  out  of  place  in  levicw- 
ing  its  action  as  a  whole. 

*  Loc.  cit. 


REACTION    OK    AlDiroRV    NKRN'E    TO    STIMl'LI.  6; 

Under  ordinary  conditions,  sonorous  impulses,  projected 
through  the  air,  reach  the  end-organ  of  the  nerve  specialized 
for  sound  perception  by  the  transmutation  of  aerial  waves  of 
condensation  and  rarefaction,  through  the  agency  of  the  tym- 
panic structures,  into  waves  of  similar  character  in  the  laby- 
rinthine fluid.  These  waves  in  turn  impress  the  terminal 
filaments  of  the  auditory  nerve  in  a  specific  manner.  Nor- 
mally, then,  sounds  are  best  heard  through  the  air;  it  is  pos- 
sible, however,  for  the  fluid  within  the  labyrinth  to  be  set  in 
vibration  through  the  medium  of  the  cranial  bones,  resulting 
in  the  phenomenon  of  sound  j^crccption.  When  the  laby- 
rinth is  intact,  musical  notes  arc  inter[)rcted  with  a  fair  de- 
gree of  accuracy  when  they  reach  the  labyrinth  bv  bone- 
conduction — that  is,  when  the  vibrating  body  is  brought  in 
contact  with  the  bones  of  the  head.  There  are  reasons  for 
believing  that  even  when  the  labyrinth  is  seriously  affected 
the  auditory  nerve  iiself  may  react  to  vibrations  which  are 
conveyed  to  it  through  the  bones  of  the  skull.  An  explana- 
tion ol  this  fact  is  offered  by  Gad,*  who  advances  the  hy- 
pothesis that  under  normal  conditions  the  auditory  nerve- 
trunk  not  only  transmits  stimuli  resulting  from  the  analysis 
of  complex  sounds  bv  the  labyrinth,  but  is  also  excited  by 
the  impulses  of  the  vibrating  body  acting  as  a  mechanical 
stimulus.  This  last  effect  will  not  be  prevented  by  the  de- 
struction of  the  portion  of  the  nerve  designed  for  the  analysis 
of  sound,  the  impression  received  affecting  the  sensorium  as 
a  whole  rather  than  as  distinct  individual  notes.  The  in- 
creased electric  irritability  of  the  nerve,  so  often  found  where 
the  labyrinth  has  been  destroyed  in  the  course  of  physio- 
logical experiments,  rather  adds  weight  to  this  view.  Even 
where  the  labyrinth  is  entirely  scjiarated  from  the  auditory 
nerve-trunk,  the  excitation  of  the  nerve  by  sounding  bodies 
of  different  j)itch  would  j)n)bably  produce  different  effects 
upon  the  perceptive  centres,  although  the  exact  differences 
could  not  be  defined  by  the  subject.  In  this  hypothesis  the 
auditory  nerve  follows  the  laws  which  govern  the  reaction  of 
all  sensory  and  motor  nerves  to  stimuli  of  various  kinds, 
whether  they  be  thermal,  mechanical,  or  electrical.  The 
weak  point  of  this  theorv  lies  in  the  fact  that  in  physiological 
experiments  one  can  never  be  certain  that  the  cochlea  has 


*  Schwartze,  Ilandb.  der  Ohren.,  1892,  vol.  i,  p.  348. 
6 


66        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

been  entirely  destroyed,  while  in  cases  of  exfoliation  of  the 
cochlea  in  man,  as  the  result  of  disease,  the  process  has  usu- 
ally been  unilateral,  and  the  part  played  by  the  unaffected 
ear  can  not  be  excluded  with  certainty.  Corradi*  has  demon- 
strated by  experiment,  that  in  the  porpoise  destruction  of 
both  cochleae  causes  complete  deafness;  but  it  is  not  safe  to 
say  that  the  same  result  will  follow  in  the  human  species.  It 
is  enough  for  practical  purposes  to  remember  that  the  exact 
interpretation  of  sound  is  only  possible  when  the  cochlea  is 
intact;  while  it  is  probable  that  the  stimulation  of  the  nerve- 
trunk  itself  may  be  effected  by  a  sounding  body  or  other 
stimulus,  even  if  the  end-organ  has  been  destroyed. 

The  Concerted  Action  of  the  Auditory  Apparatus. — It  is 
still  a  question  of  dispute  as  to  the  exact  influence  exerted  by 
the  auditory  organ  of  one  side  upon  that  of  the  opposite  side 
of  the  body.  Unquestionably  the  hearing  is  most  delicate 
when  both  organs  are  in  perfect  condition.  If  one  ear  is 
occluded  by  the  finger  or  obstructed  from  any  pathological 
process,  sound  perception  becomes  less  acute,  and  the  power 
to  distinguish  the  location  of  a  sounding  body  is  correspond- 
ingly interfered  with.  No  doubt  the  correlation  of  the  organs 
of  the  opposite  sides  depends  largely  upon  the  decussation  of 
the  fibres  of  the  cochlear  nerve  in  the  brain,  as  described  in  the 
pages  devoted  to  anatomy  of  the  auditory  nerve.  It  must  be 
remembered,  however,  that  if  perfect  audition  presupposes  the 
anatomical  perfection  of  both  organs,  a  condition  might  exist 
in  which  the  transmission  of  sonorous  waves  by  the  apparatus 
of  one  side  would  be  so  incorrect  as  to  interfere  with  the 
perception  of  those  conveyed  through  the  auditory  organ  of 
the  opposite  side.  Cases  are  met  with  in  which  the  hearing 
can  be  improved  by  completely  occluding  one  ear  artificially, 
thus  excluding  the  sound  waves  from  it.  That  in  the  normal 
subject  binaural  audition  is  better  than  monaural  is  explained, 
according  to  Urbantschitsch,f  by  the  fact  that  the  stimulation 
of  the  peripheral  organ  of  the  auditory  nerve  on  one  side,  ren- 
ders the  perceptive  centre  on  the  corresponding  side,  and  which 
receives  fibres  from  the  opposite  car,  more  susceptible  to  the 
action  of  the  sound  waves.  This  excitation  of  the  receptive 
centre    renders   it   responsive    to    slight   stinuili    reaching    it 


*  Archiv  fiir  Ohrenheilk,  vol.  xxxii,  p.  i. 

f  Lehib.  der  Ohren.,  Wicn,  1890,  p.  416.     Arch,  fiir  Ohrenheilk  ,  vol.  xxxv,  p.  i. 


RKFLKX    PHENOMENA.  67 

throu2:h  the  opposite  car.  In  support  of  this  argument,  we 
recall  the  fact  that  the  acutencss  of  audition  upon  one  side 
for  any  given  s(jund  will  be  increased  if  the  organ  of  the 
opposite  side  is  at  the  same  time  brought  uiuier  the  intlucnce 
of  sound  waves  of  a  different  character  ;  thus,  loi"  instance,  a 
watch  may  be  more  clearlv  perceived  in  the  right  car  if  a 
vibrating  tuning  fc^rk  is  held  close  to  the  meatus  ol  the  left. 
In  this  way  Crl)antschitsch  explains  the  phenomenon  of  para- 
cousis  Willisii,  the  action  of  hnid  sounds  serving  to  stimulate 
the  receptive  centres,  after  which  relatively  feeble  stimuli,  as 
vibrations  of  sinall  amplitude,  may  be  perceived.  Binaural 
audition,  then,  would  owe  its  acuteness  to  the  exciting  action 
of  one  auditory  centre  uj)on  the  other.  Politzer,*  on  the 
other  hand,  believes  that  the  greater  acuteness  of  binaural 
audition  depends  upon  the  lact  that  it  represents  the  effect 
of  an  impulse  acting  upon  a  greater  area,  and  hence  pro- 
ducing a  more  marked  impression,  upon  purely  mechanical 
principles.  This  latter  suggestion  seems  the  more  simi)le,  and 
vet  a  close  observation  ol  the  phenomena  produced  by  vari- 
ous pathological  processes  reveals  the  existence  of  such  an 
intimate  interdcjiendencc  between  the  organs  of  the  opposite 
sides,  that  it  is  hard  to  believe  that  this  association  does  not 
play  an  important  part  under  nc^rmal  as  well  as  under  patho- 
logical C(  indition^. 

Reflex  Phenomena.— We  have  spoken  at  length  of  the  ac- 
tion of  one  auditory  organ  upon  the  other,  but  it  must  not  be 
forgotten  that  the  nucleus  of  the  eighth  nerve  of  either  side 
communicates  not  only  with  its  fellow,  but  is  intimately  asso- 
ciated with  the  central  nuclei  of  the  other  cnmial  nerves,  as 
well  as  with  various  spinal  centres.  The  function  of  the  ear 
is  affected  not  only  by  the  action  of  sonorous  waves,  but  also 
reflexly  by  the  action  of  various  stimuli  upon  other  centres 
with  which  the  auditory  is  in  intimate  relati(jn.  Conversely, 
any  excitation  of  the  sound-perceiving  apparatus  may  effect 
psychical,  sensory,  or  motor  changes  in  remote  regions  of 
the  body.  The  phenomenon,  often  observed,  of  starting  at 
any  sudden  sound  undoubtedly  depends  upon  reflex  action ; 
the  association  between  particular  sounds  various  colors  and 
is  an  example  of  the  curious  efTect  produced  on  account  of 
the  communicating  fibres   between   the   acoustic  and   visual 

*  op.  cit.,  p.  516. 


68         THE    ANATOMY    AND    PHVSIOLOC.Y    OF    THE    EAR. 

centres.  On  the  other  hand,  the  power  of  audition  maybe 
perverted  or  annulled  reflexly,  by  a  pathological  condition 
affecting  fibres  of  a  nerve  trunk,  the  centres  of  which  are  in- 
timately associated  w-ith  the  auditory  nerve  nuclei. 

Phenomena  dependent  upon  Circulatory  Changes. — 
Througfh  the  intimate  iclation  which  exists  between  the 
blood-vessels  of  the  labyrinth,  the  tympanum,  the  higher  nerve 
centres  presiding  over  audition  and  the  cervical  sympathetic, 
it  is  plain  that  circulatory  changes  must  exert  an  important  in- 
fluence upon  the  function  of  audition,  perverting  or  impairing 
it,  either  indirectly  by  inducing  vascular  changes  within  the 
tympanum  or  directly  by  causing  circulatory  changes  in  the 
end  organ  or  ganglia  of  the  eighth  nerve.  This  tact  is  to  be 
particularly  remembered  in  considering  certain  subjective 
symptoms  frequently  complained  of,  experience  showing  that 
correction  of  vaso-motor  tone  often  relieves  the  manifesta- 
tions. On  the  other  hand,  disturbances  in  the  blood  supply 
may  depend  upon  actual  organic  changes  in  the  vessels  or  in 
the  blood  itself.  It  is  evident,  especially  in  the  consideration 
of  subjective  phenomena,  that  there  exists  a  broad  field  for 
speculation,  not  only  in  diagnosis,  but  also  in  the  selection 
of  appropriate  therapeutic  measures. 

Secondary  Phenomena. — In  this  same  line  lie  those  dis- 
turbances, both  objective  and  subjective,  which  depend  upon 
a  morbid  process  in  some  other  organ  of  the  body.  Here  we 
may  mention  the  symptoms  met  with  in  connection  with  con- 
gestive derangements  of  the  larger  viscera,  and  relieved  only 
by  remedies  appropriate  for  the  correction  of  the  exciting 
cause.  Disturbance  of  the  auditory  centres  in  the  female  is 
not  uncommon  in  uterine  and  ovarian  disorders. 

The  relation  between  ocular  and  aural  derangements  has 
lately  been  emphasized  by  Oliver  and  Cleveland  ;  *  many  of 
these  must  be  reflex  in  character.  The  reflex  disturbances  of 
the  most  importance  are  those  occurring  in  the  domain  of 
the  trigeminal  nerve.  This  nerve  supplies  many  filaments  to 
the  external  and  middle  ear,  and  in  the  latter  location,  it  will 
be  remembered,  a  close  association  exists  between  the  cranial 
and  sympathetic  nerves.  As  a  result,  any  morbid  condition 
which  involves  parts   supplied    by  the    trigeminus  may,  by 

*  Burnett's  System  of  Diseases  of  the  Ear,  Nose,  and  Throat.     Philadelphia,  i8g3, 
vol.  i,  p.  516. 


Mx»)NnARV    rHF.\(^MF.NA.  69 

involvement  of  the  nerve  elements  which  thev  contain,  so 
interfere  with  the  trophic  supply  of  some  portion  of  the  ear 
as  to  cause  not  onlv  functional  disturbances  but  even  organic 
changes  in  the  tissues. 

In  this  connection  the  inlluence  of  dental  caries  is  the  most 
familiar  instance,  it  having  been  proved  that  decaved  teeth 
may  produce  not  only  a  functional  disturbance  of  the  organ 
of  hearing,  but  also  an  acute  inflammation  of  the  tympanum. 
Most  interesting,  also,  is  the  close  relation  bet\yeen  corre- 
sponding parts  of  the  auditory  apparatus  of  the  opposite  sides 
of  the  body.  Here,  no  doubt,  the  phenomena  observed  de- 
pend upon  reflex  action  through  the  SN'mpathctic  and  cranial 
nerves  and,  in  many  cases,  upon  the  decussation  of  the  audi- 
tory fibres  within  the  brain.  The  effect  is  at  first  refiex  in 
character,  but  later  the  result  of  degeneration  or  atrophy. 
The  so-called  "  sympathy  "  between  the  ear  of  one  side  with 
that  of  its  fellow  was  recognized  by  Kramer.*  Wharton  Jones. + 
and  many  other  early  writers.  Recently  L'rbantschitsch  :{:  has 
written  extensively  upon  the  subject. 

The  effect  of  increased  labyrinthine  tension  from  rigidity 
and  displacement  inward  of  the  ossicular  chain  upon  the  func- 
tion of  the  opposite  ear  is  made  prominent  l)y  Weber-Liel  * 
and  by  Cholewa.  The  writer^  has  also  called  attention  to  the 
fact,  especially  in  cases  operated  upon  for  chronic  infiamma- 
tory  conditions  of  the  tymi)anum.  that  the  function  of  the  op- 
posite ear  has  been  improved  after  operation.  Gelle  ()  is  in- 
clined to  look  upon  the  temporary  impairment  of  function 
observed  when  the  meatus  is  closed  with  the  finger,  while  at 
the  same  time  a  vibrating  body  is  held  close  to  the  unob- 
structed meatus,  as  due  to  a  reflex  contraction  of  the  ten- 
sor tympani  muscle  upon  the  non-occluded  side,  and  makes 
use  of  the  ex{)erinK'nt  to  prove  tiic  integrity  of  the  upper  cer- 
vical nerves,  these  being  comprised  in  the  refiex  chain.     It 


*  Ohrenheilk.,  1836,  p.  145. 

f  Frank's  Ohrenheilk..  1845,  p.  133. 

X  .Arch,  fiir  Ohrenheilk,  1893.  vol.  xxxv.  p.  i. 

*  Monatsschr.  fiir  Ohrenheilk,  1S74,  No.  6. 
I  .Vrch.  of  Otol.,  vol.  xix,  p.  151. 

^  N.  V.  Eye  and  Ear  Infirmary  Reports,  vol.  i,  p.  50,  vol.  ii,  p,  62.  Wood's 
Reference  Handbook  of  the  Medical  Sciences.  New  York,  1893.  (Supplement.) 
Art.  "  Middle  Ear  Operations," 

0  .\rch.  fiir  (  )hrenheilk,  vol.  xxviii,  p.  58. 


-JO        THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

seems  to  me  that  the  manifestation  can  be  better  accounted 
for  by  the  direct  effect  of  the  pressure  upon  the  end  organ  of 
the  acoustic  nerve,  and  the  transmission  of  the  stimulus  to  the 
perceptive  centres  of  both  sides. 

Like  other  nerves,  the  auditory  trunk  may  be  rendered 
less  capable  of  transmitting  impulses  either  by  overuse  or 
disuse,  and  for  the  same  reasons  the  higher  receptive  cen- 
tres may  cease  to  functionate  properly.  Thus,  if  the  ear  is 
subjected  for  a  long  time  to  the  action  of  a  single  sound,  this 
particular  note  will,  after  a  time,  cease  to  be  perceived  as 
readily  as  at  the  beginning  of  the  experiment,  although  per- 
ception for  other  notes  of  the  scale  will  be  unaffected.  If,  on 
the  other  hand,  the  nerve  is  allowed  to  remain  inactive  for  a 
long  period,  as  where  serious  obstruction  to  sound  conduc- 
tion has  rendered  the  ear  of  little  practical  use,  it  is  found 
that  even  after  the  removal  of  the  obstruction  and  the  resto- 
ration of  the  conducting  mechanism  to  a  normal  condition, 
the  function  of  the  ear  is  imperfect  from  the  fact  that  the 
nerve  has  been  so  long  at  rest  that  it  is  not  able  to  subserve 
the  purpose  for  which  it  was  designed.  On  the  other  hand, 
after  the  nerve  trunk  and  receptive  centres  have  been  once 
excited,  they  react  more  readilv  to  stimuli  and  require  less 
enersfv  to  maintain  them  in  a  condition  of  irritabilitv  than 
would  be  required  to  arouse  them  from  a  state  of  repose.  It 
is  frequently  found,  in  testing  the  hearing  with  a  watch  or 
other  similar  instrument,  that  the  hearing  distance  will  be 
greater  if  the  sounding  body  is  first  held  close  to  the  ear  and 
then  gradually  withdrawn  until  it  is  no  longer  heard,  than 
if  the  experiment  is  reversed  :  the  sounding  body  being 
gradually  carried  toward  the  ear  from  a  point  at  which  it  is 
not  perceived  until  a  position  is  reached  where  it  is  distinctlv 
audible.  This  means  simplv  that  the  auditory  nerve  having 
once  been  excited,  reacts  to  a  stimulus  of  less  intensitv  than 
that  required  for  its  initial  excitation.  On  account  of  the 
decussation  of  the  auditory  fibres  in  the  medulla,  it  is  also 
true  that  the  functional  activity  of  the  ear  on  one  side  niav 
be  increased  by  stimuli  directed  to  the  opposite  car. 

Urbantschitsch  *  exj)lains  this  upon  the  hypothesis  that  the 
excitation  of  the  cortical  centre  of  one  side  by  means  of  sono- 
rous vibrations  acting  upon  the  opposite  ear  renders  sound  per- 


*  Lehrb.  dcr  Oliien.,  1890,  p.  416. 


HVPER.-ESTHKSIA    AND    I'AR/ESTHESIA.  y\ 

ception  more  acute  in  the  other  ear  on  account  of  the  decussa- 
tion of  the  auditory  hbres,  through  which  the  cortical  centre 
receives  fibres  from  the  labyrinth  of  the  corresponding-  and 
opposite  sides.  Stimulation  of  the  opposite  labyrinth  increases 
the  irritability  of  the  centre  and  causes  it  to  respond  to  a 
slighter  stimulus,  whether  this  is  received  through  the  cor- 
responding or  opposite  end  organ.  I  have  already  suggested 
such  an  influence  in  explaining  the  improvement  observed  in 
the  organ  not  operated  upon  in  cases  subjected  to  operative 
procedures.  Urbantschitsch  *  has  so  extended  the  field  of 
possible  utility  in  this  direction  that  it  is  of  the  utmost  im- 
portance to  bear  the  relation  in  mind  on  account  of  its  thera- 
peutic usefulness.  This  writer  urges  that  this  stimulation  of 
the  perceptive  centres  may  follow  the  action  of  sonorous 
vibrations,  even  if  the  ear  acted  upon  is  so  defective  as  to  be 
incapable  of  transmitting  impulses  to  the  degree  necessary  for 
actual  sound  perception  on  the  part  of  the  patient.  In  other 
words,  when  the  organ  of  one  side  has  been  rendered  entirely 
useless  by  sclerotic  changes  in  the  conducting  mechanism,  he 
deems  it  warrantable  to  relieve  this  physical  abnormality  be- 
fore the  inlluence  which  it  may  exert  u[jon  the  opposite  side 
can  be  decided. 

We  have  discussed  the  effect  upon  the  rece[^tive  centres 
of  overstimulation  by  sonorous  waves,  and  also  the  result  fol- 
lowing a  long  period  of  inactivity.  It  must  be  remembered 
that,  like  other  nerve  centres,  the  auditory  nuclei  and  fibres 
react  to  other  stimuli  than  those  for  which  they  were  espe- 
cially designed.  Pressure  upon  the  terminal  filaments,  trunk, 
or  centre  of  the  eighth  nerve  excites,  perverts,  or  destroys  its 
function.  Slightly  increased  pressure  upon  the  terminal  fila- 
ments, from  congestiijn  of  the  labyrinth,  may  render  the  nerve 
exceedingly  sensitive,  and  may  give  rise  to  subjective  noises 
(paracsthesiiu).  One  of  the  most  curious  effects  observed 
from  this  increased  activity  is  the  persistence  of  auditory 
impressions;  for  example,  when  a  certain  piece  of  music  is 
played  upon  the  piano,  the  hyperaesthetic  centre  may  retain 
a  mental  picture  of  this  for  a  long  period,  and  the  individual 
be  annoyed  for  hours  afterward  by  the  subjective  impression 
of  hearing  the  selection  continually,  exactly  as  it  has  been 
played  originally.     In  the  same  manner  it  is  not  an  uncom- 

*  Arch,  fiir  Ohrenheilk.,  vol.  xxxv,  p.  i. 


72 


THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 


mon  experience  for  patients  to  aver  that  they  hear  the  tick 
of  a  watch  even  after  the  sound  has  ceased,  the  impression 
once  received  being  maintained  for  a  long  interval.  It  is  of 
great  importance  to  bear  this  in  mind  in  testing  the  hearing 
with  any  instrument,  such  as  the  watch  or  acoumeter,  where 
the  same  sound  is  repeated,  as  otherwise  erroneous  conclu- 
sions will  be  reached. 

Too  great  stimulation,  either  on  account  of  the  sudden 
condensation  of  air  in  the  auditory  canal,  as  when  a  loud  ex- 
plosion takes  place  close  to  the  ear,  or  by  loud  sounds  con- 
tinued for  a  considerable  period,  may  cause  great  impairment 
of  hearing  for  varying  intervals  of  time,  the  sudden  increase 
in  pressure,  on  the  one  hand,  or  the  prolonged  and  intense 
excitation  on  the  other,  completely  destroying  either  tran- 
sientlv  or  permancntlv  the  function  of  the  delicate  perceptive 
portions  of  the  auditory  system.  Familiar  examples  of  these 
effects  are  observed  among  artillerymen,  in  whom  a  tempo- 
rary impairment  of  hearing  is  not  uncommon,  after  exercise 
with  the  great  guns  of  the  battery.  Among  soldiers  who 
have  been  under  heavy  fire  for  many  days,  the  prolonged 
and  excessive  excitation  of  the  receptive  centre  or  of  the 
terminal  filaments  of  the  nerve  has  been  known  to  produce 
permanent  results,  although  usually  the  impairment  has  been 
but  temporary. 


CHAPTER    111. 

rilVSlCAl.    KXAMINATK^N. 

Preliminary  Observations. — Before  describinp;-  in  detail  the 
instniniciUs  needed  lor  the'  j)roper  examination  of  the  ear,  let 
us  recall  briefly  the  topoj^raphy  of  the  region. 

The  external  meatus  is  made  up  of  two  tubes,  joined  at  an 
angle  in  both  the  vertical  and  horizontal  planes,  re-entrant 
downward  and  forwanl.  The  fundus  of  this  canal  constitutes 
the  drum  membrane,  and  is  continuous  with  its  cutaneous  lin- 
ing. The  length  of  the  entire  fjassagc,  measured  from  its  out- 
ermost point — that  is.  from  the  tragus  to  the  drum  membrane 
— is  thirty-six  millimetres,  or  about  one  inch  and  a  half.  This 
should  be  remembered  as  de- 
termining the  jiro|»er  length  of 
instruments  to  be  manipulated 
in  the  meatus.  It  should  also  be 
borne  in  mind  that  of  this  inch 
and  a  half,  a  little  less  than  one 
inch  of  the  tube  is  cartilaginous 
and  a  little  over  half  an  inch 
osseous.  The  general  direction 
of  the  cartilaginous  tube  is  up- 
ward, backward,  and  inward, 
while  that  of  the  bony  conduit 
is  downward,  forward,  and  in- 
ward. For  the  satisfactory  in- 
spection of  the  deeper  parts,  it 
is  evident  that  the  axes  of  these 
canals  must  be  made  as  nearly  as 
possible  coincident  ;  as  the  out- 
er portion  is  movable,  traction 
upon  the  auricle  uj)ward  and 
backward  tends  to  bring  the  axes  into  the  same  straight  line. 

Fig.  25  illustrates  the  position  assumed  by  the  parts  in  the 
adult  when  the  auricle  is  drawn  upward,  backward,  and  out- 

(73) 


Flo.  25. — Pen-drawing  from  adult 
specimen,  showing  the  result  of 
drawing  the  auricle  upward  and 
backward.  The  axes  of  the  bony 
and  cartilaginous  meatus  are  made 
coincident,  permitttng  an  inspec- 
tion of  the  drum  membrane  (actual 
size). 


74 


PHYSICAL    EXAMINATION. 


ward.  It  will  be  seen  that  the  cartilaginous  and  bony  meatus 
form  practically  a  straight  canal,  the  angle  marking  their 
junction  having  been  obliterated  by  traction  in  the  directions 
named. 

In  infants  the  superior  and  inferior  walls  of  the  meatus  are 
in  contact  and  must  be  separated  before  the  membrana  tym- 
pani  can  be  seen.  This  is  due  to  the  absence  of  the  bony 
meatus  at  birth.  As  the  superior  w^all  of  the  fibro-cartilaginous 
tube  is  attached  to  the  squama,  the  separation  of  the  walls  can 
be  effected  only  by  traction  downward  and  backward,  the  in- 
ferior wall  being  pulled  away,  so  to  sj)eak,  from  the  superior 
wall.     Fig.  26  clearly  demonstrates  this  fact,  and  it  should  be 


Fig.  26. — Drawing  from  specimen  at 
birth.  Traction  must  be  made  down- 
ward and  backward  to  expose  llie 
membrana  tympani  (actual  size). 


Fk;.  27. — Drawing  from  specimen  from 
child,  aged  live  years.  The  develop- 
ment of  the  bony  meatus  has  separated 
the  superior  and  inferior  walls,  but 
traction  downward  will  still  expose  the 
membrana  tympani  most  completely 
(actual  size). 


remembered  that  it:  yoimg  children  the  atiricle  should  be 
drawn  outward,  backward,  and  downward  in  making  a  specu- 
lum examination. 

In  children  several  years  old  the  development  of  the  bony 
canal  has  effected  this  separation  of  the  w\alls  of  the  deep 
meatus,  but  even  in  these  cases  the  membrana  tvmpani  is 
more  clearly  seen  if  the  auricle  is  drawn  slightly  downward 
rather  than  upward.  Fig.  27,  drawn  from  a  specimen  taken 
from  a  child  of  five,  makes  this  clear. 

Since  the  cartilasrinous  meatus  alone  is  dilatable,  the  field 
of  inspection    can  not  be   increased   in  size   by  crowding    a 


PRELIMINARY    OBSERX'ATIONS. 


75 


dilating  instrument  beyond  the  ossco-cartilaginous  junction. 
On  the  other  hand,  since  such  a  procedure  hxes  the  two  por- 
tions imniovablyat  their  anii^le  of  union,  the  held  ol  insjiection 
must  be  considerably  narrowed.  Moreoyer,  an  instiunient  ol 
greater  external  dimensions  tiian  the  calibre  of  the  libro- 
cartilagin(nis  tube  will  crowd  the  soft  parts  inward  toward 
the  fibro-osseous  junction,  and  this  mass  will  obstruct  the  yiew 
of  the  deeper  parts. 

The  fundus  of  the  canal  is  formed  by  the  drum  membrane. 
This  is  obliquely  placed  both  in  the  horizontal  and  vertical 
planes  of  the  h^ng  axis  of  the  meatus.  The  inferior  margin 
of  the  membrane  forms  an  angle  with  the  horizontal  plane  of 
from  thirty  to  forty  degrees,  while  the  anterior  margin  makes 
an  angle  ui  about  one  hundred  degrees  with  the  vertical  me- 
dian antero-posterior  plane  of  the  body.  From  the  confor- 
maticjn  of  the  meatus  at  its  inner  extremity,  the  angles  which 
the  membrana  tympani  makes  with  the  posterior  and  suj)erior 
walls  are  somewhat  greater  than  those  made  with  the  vertical 
and  horizontal  planes.  In  other  words,  the  drum  tiiembrane 
is  really  a  continuation  of  the  superior  wall  of  the  meatus, 
and.  to  a  less  extent,  of  the  posterior.  1-rom  this  it  follows 
that  the  superior  and  j)osterior  margins  of  the  membrane  arc 
nearer  the  orifice  of  the  meatus  than  the  inlei  ior  and  anterior. 
In  the  young  infant  the  membrana  tymjtani  lies  in  the  plane 
of  the  surface  of  the  s(]uama.  To  be  brought  intcj  view  the 
operator  must  direct  his  glance  uj)ward  toward  the  sujjerior 
^vall  of  the  canal. 

In  investigating  diseases  of  the  ear  it  has  been  the  custom 
to  lay  special  emjihasis  upon  the  aj'pearance  of  the  drum 
membrane  as  observed  upon  ocular  ins|)ection,  and  to  form 
opinions  as  to  the  prognosis  of  any  malady  largely  from  the 
information  thus  obtained.  It  should  be  remembered  that  in 
most  cases  we  are  consulted  for  an  impairment  or  peryersion 
of  the  function  of  the  organ,  and  hence,  while  inspection  of 
the  visible  parts  is  very  important  and  should  be  made  with 
all  the  skill  attainable,  it  is  also  equally  important  to  conduct 
a  systematic  functional  examination,  for  the  discovery  of  the 
location,  extent,  and  nature  of  the  pathological  condili(jn  re- 
sponsible for  the  symptoms  complained  of  by  the  patient,  and 
to  determine  as  well  to  what  extent  the  power  of  sound  per- 
ception is  interfered  with,  the  normal  ear  being  taken  as  the 
standard  in  conducting:  such   tests.     In  this  manner  we  can 


76  PHYSICAL    EXAMINATION. 

more  intelligibly  estimate  the  amount  of  damage  done,  and, 
combining  the  information  obtained  both  from  functional  and 
physical  examination,  we  arrive  at  an  opinion  of  greater  value 
than  that  obtained  by  ocular  inspection  merely. 

To  properly  examine  the  parts  so  situated  as  to  be  open 
to  ocular  inspection  it  is  necessary  to  secure  a  proper  illumi- 
nation of  the  region.  From  the  depth  and  sinuous  course  of 
the  auditory  meatus,  examination  by  direct  illumination  has 
never  been  as  successful  as  when  the  light  has  been  reflected 
upon  the  parts  bv  means  of  a  mirror. 

The  Source  of  Light. — We  have  to  consider,  in  the  first 
place,  the  source  of  light.  If  sunlight  could  always  be  de- 
pended upon  it  would,  no  doubt,  be  the  best  source  of  illumi- 
nation for  an  otoscopic  examination.  The  direct  rays  of  the 
sun,  when  reflected  into  the  ear,  produce  such  a  brilliant  illu- 
mination of  the  parts  that  detail  is  obscured.  Diffuse  day- 
light or  light  from  a  white  cloud  forms  a  very  perfect  source 
of  illumination,  but  naturally  can  not  always  be  obtained.  I 
am  in  the  habit,  therefore,  of  advising  students  to  accustom 
themselves  to  the  various  appearances  as  seen  by  artificial 
light.  An  ordinary  oil  lamp,  if  fitted  with  a  duplex  or  other 
powerful  burner,  is  an  excellent  source  of  illumination.  The 
same  can  be  said  of  an  Argand  gas-burner;  even  a  common 
candle  emits  sufficient  light  to  enable  the  surgeon  to  make  a 
perfect  examination,  and  to  perform  anv  operation  within  the 
canal  which  an  emergencv  might  demand.  At  least  one  of 
these  means  of  artificial  illumination  can  be  found  in  anv 
house,  and  familiaritv  with  normal  and  pathological  appear- 
ances when  viewed  by  such  light  can  not  fail  to  be  of  great 
service  to  the  otologist,  who  is  often  obliged  to  make  an 
examination  at  the  bedside.  For  convenience  in  making  an 
examination  at  the  bedside,  as  an  adequate  source  of  illumina- 
tion may  not  always  be  obtainable  without  delav,  or  mav  de- 
mand the  aid  of  an  assistant  to  permit  of  a  proper  examination 
without  moving  the  patient,  it  is  well  for  the  examiner  to  be 
provided  for  such  an  emergency.  For  this  purpose  use  may 
be  made  of  the  device  shown  in  Fig.  28,  which  consists  of  a 
clamp  which  may  be  fastened  to  a  table,  chair,  the  frame  of 
the  bedstead,  or  any  other  firm  object  in  the  room,  as  may 
be  convenient.  This  clamp  carries  a  jointed  rod,  which  sup- 
ports a  short  arm  for  holding  an  ordinary  candle.  For  city 
practice  the  ordinary  fish-tail  gas-burner  may  be  substituted 


THi;    Sc)LRCi:    OF    LIGHT. 


17 


in  place  of  the  candle,  the  burner  being-  attached  lo  a  small 
metal  band  which  fits  into  the  candle-holder.  This  burner  is 
connected  with  a  gas  fixture  in  the  room  bv  means  of  a  fiexi- 


f 


Fig.  28 — -.^uthor's  portable  illuminating  a;iparatus.  In  the  figure  the  candle  and 
electric  lamp  are  in  position  ;  the  gas-burner  is  shown  in  the  detached  drawmg 
on  the  left. 


78  PHYSICAL    EXAMINATION. 

ble  pipe  attached  to  it.  This  apparatus  enables  one  to  secure 
a  fairly  efficient  source  of  illumination  and  to  place  the  light 
in  exactly  the  position  from  which  he  may  make  the  examina- 
tion with  greatest  comfort  to  the  patient  and  to  himself,  and 
renders  the  entire  procedure  less  laborious  and  correspond- 
ingly more  exact.  The  entire  apparatus  occupies  but  little 
space  in  the  instrument  bag,  and  greatly  facilitates  bedside  ex- 
amination. A  small  electric  lamp  suitable  for  operative  work 
can  also  be  attached  to  the  vertical  rod,  while  a  light  shelf  for 
supporting  an  oil  lamp  can  be  fitted  upon  the  arm  carrying 
the  candle,  if  the  examiner  prefers  this  source  of  illumination. 

The  different  appearance  of  the  parts  viewed  bv  artificial 
light  as  compared  with  the  picture  seen  when  diffuse  day- 
light is  emploved,  depends  upon  the  fact  that  all  artificial 
sources  of  illumination  contain  a  preponderance  of  yellow  ravs, 
and  hence  the  reds  and  yellows  are  slightly  exaggerated  in 
the  otoscopic  picture.  No  mistake  need  be  made  if  this  fact 
is  borne  in  mind,  even  by  an  observer  accustomed  to  the 
use  of  white  light. 

Since  the  introduction  of  electricity  as  an  illuminating 
agent  its  employment  in  otological  work  has  become  quite 
common.  The  rays  which  the  incandescent  lamp  yields  are 
almost  colorless,  and  any  desired  intensity  can  be  obtained. 
The  reflected  image  of  the  luminous  carbon  band  sometimes 
gives  rise  to  annoyance — a  difficulty  which  can  be  obviated  by 
the  employment  of  a  system  of  mirrors,  the  effect  of  which  is 
to  obliterate  the  image  entirely  and  yield  only  a  diffuse  white 
light,  which  the  surgeon  can  then  reflect  into  the  ear  by  means 
of  the  mirror.  A  manifest  objection  to  tiie  electric  light  lies 
in  the  fact  that  it  is  not  always  obtainable,  although  this  is  in 
a  measure  overcome  bv  the  introduction  of  portable  storage 
batteries.  Its  greatest  advantage  is  that  when  ether  anaesthesia 
is  required,  there  is  no  danger  of  ignition  of  the  vapor,  since 
the  luminous  carbon  is  completely  inclosed. 

As  electricity,  even  when  carefully  handled,  is  a  somewhat 
capricious  agent,  it  is  well  for  the  operator  to  be  supplied  with 
an  additional  source  of  illumination  in  every  case,  so  that  in 
the  event  of  the  electric  apparatus;  failing,  some  other  efficient 
means  may  be  at  hand. 

The  Reflecting  Mirror.  —  It  was  formerly  the  practice  in 
examining  the  ear  by  means  of  reflected  light,  to  direct  the 
rays  into  the  canal  by  a  plane  or  concave  mirror  fixed  upon  a 


THE    REFLECTINT,    MIRROR. 


79 


short  handle  (Fig-.  29),  and  held  in  one  hand,  while  the  other 
hand  grasped  the  auricle  and  supported  the  speculum  in  the 
proper  position.  Obviously  the  most 
correct  information  is  obtainable  bv 
the  simultaneous  inspection  and  ma- 
nipulation of  the  parts;  it  is  necessary, 
therefore,  that  the  surgeon  have  one 
hand  free  for  the  use  of  a  delicate 
j)robe.  At  the  present  day  the  reflect- 
ing mirror  is  usually  worn  upon  the 
forehead,  and  the  |)olished  surface  is 
concave,  thus  bringing  the  luminous 
rays  to  a  focus  in  front  of  the  mirror. 
The  light  will  be  most  intense  at  the 
princi{)al  focus  of  the  instrument,  and 
the  best  definition  will  be  obtained  at 
a  point  just  within  this  ;  hence  the  focal 
distance  of  the  miiior  should  be  such 
that  when  the  parts  are  perfectly  il- 
luminated, the  eve  may  be  as  near  as 
possible  to  tlic  region  to  be  examined, 
while  at  the  same  time  sufficient  space 
intervenes  between  the  ear  of  the  pa- 
tient and  the  surface  of  the  mirror  for 
the  manipulation  of  such   instruments 

as  it  may  be  necessary  to  use.  It  is  seldom  practicable  for 
the  eye  of  the  observer  to  be  less  than  eight  or  ten  inches 
Irom  the  deepest  part  of  the  region  under  inspection.  In 
selecting^  a  mirror,  therefore,  the  focal  distance  should  not 
be  less  than  seven  inches,  nor  more  than  eleven  inches.  This 
fact  should  be  borne  in  mind  in  choosing  the  instrument,  and 
can  be  most  easily  ascertained  bv  noting  the  distance  between 
the  inirror  and  the  hand  when  the  ravs  of  light  are  brought 
to  a  focus  ujK)n  the  {)alm.  Where  artificial  light  is  used,  the 
rays  are  divergent,  and  hence  the  conjugate  focus  for  such 
rays  will  be  more  remote  than  the  principal  focus,  which  is 
the  point  to  which  the  parallel  ravs  are  converged.  It  is  also 
advisable  to  be  provided  with  a  mirror  which  will  serve  for 
an  examination  of  the  ear,  and  of  the  nose  and  naso-pharynx  as 
well.  For  the  inspection  of  the  regions  last  named  the  focal 
length  of  the  mirror  should  be  slightly  greater  than  of  one 
which  is  suitable  for   otological   work   alone.      A  mirror   of 


8o 


PHYSICAL    EXAMINATION. 


from  eight  to  ten  inches  focal  length  for  divergent  rays  is  well 
adapted  to  general  use,  it  being  only  necessary  to  move  the 
source  of  light  a  little  nearer  the  mirror  when  the  throat  or 

nose  is  to  be  exam- 
ined. 

If  the  illuminat- 
ing apparatus  is  pro- 
vided with  a  con- 
densing lens  which 
renders  the  rays 
parallel,  the  focal 
distance  as  deter- 
mined by  sunlight 
will  be  correct ; 
otherwise  a  mir- 
ror of  shorter  focal 
length  for  parallel 
rays  than  that  given 
above  should  be  se- 
lected. It  is  easy 
to  determine  wheth- 
er the  mirror  is  per- 
fectly ground  bv  observing  the  image  of  the  gas  flame  or 
candle  at  the  focal  point  of  the  mirror ;  if  the  rays  are 
thrown  upon  the  hand  or  upon  a  sheet  of  white  paper,  we 
should  secure  a  sharply  defined  image  of  the  particular  flame 
with  which  we  are  experimenting;  if  the  edges  of  the  image 
are  blurred,  the  mirror  is  practically  useless  for  delicate 
work.  The  size  of  the  mirror  is  also  important;  those  sold 
in  the  shops  are  usually  perforated  in  the  centre,  the  mir- 
ror being  worn  in  such  manner  that  the  perforation  will  lie 
over  one  or  the  other  eye,  thus  bringing  the  visual  ray  of 
the  examiner  through  the  centre  of  the  cone  of  reflected  light. 
When  the  mirror  is  worn  in  this  wav  its  diameter  should  not 
be  greater  than  three  and  a  half  inches  ;  a  diameter  of  two  and 
a  half  inches  is  fully  sufficient. 

Certain  observers  prefer  to  wear  the  mirror  upon  the  fore- 
head, in  which  case  the  eye  of  the  examiner  does  not  look 
directly  through  the  cone  of  light,  the  rays  illuminating  the 
parts  to  be  inspected  being  reflected  from  them  at  an  acute 
angle  to  the  eye  of  the  observer.  When  this  method  of  exam- 
ination is  employed  the  diameter  of  the  mirror  is  immaterial. 


¥\G.  30. — Reflectinf^  mirror,  adaptcil   for  use  both  as  a 
head  or  hand  mirror. 


THE    REFLFXTING    MIRROR. 


8i 


but  nothing  is  gained  by  increasing  the  area  of  the  reflecting 
surface.  Still  other  observers  wear  the  mirror  in  such  way 
that  its  superior  border  is  below  the  orbits,  the  mirror  lying 
directly  over  the  nose,  and  the  examiner  looks  over  the  top  of 
the  glass  rather  than  through  its  centre.  It  certainly  seems 
more  simple  to  perfectly  illuminate  the  parts  by  the  first 
method  of  examination,  since  the  position  which  permits  of 
the  most  perfect  inspection  gives  at  the  same  time  the  most 
perfect  illumination.  This,  however,  is  a  matter  of  practice, 
and  after  becoming  accustomed  to  one  method  of  examina- 
tion it  is  unnecessary  to  change,  equally  good  work  being 
possible  bv  all  methods.  It  should  be  em|)hasized,  however, 
that  the  beginner  will  do  well  to  emj)l(>y  one  method  con- 
stantlv,  and  not  attempt  to  be- 
come expert  at  several. 

Sometimes  the  source  of  lii^lit 


Fig.  31.— Hta<l  nunui,  with  nasal  support. 


Fig.  32. — Head  mirror. 


ii  an  incandescent  lamp  worn  upon  the  head  of  the  exam- 
iner, the  instrument  being  provided  with  lenses  which  focus 
the  rays  ujjon  the  parts  to  be  inspected  :  such  a  light  is  worn 
either  upon  the  forehead  (Fig.  33)  or  lower  down  upon  the 
bridge  of  the  nose.  Considerable  practice  is  necessary  in 
order  to  become  expert  in  the  use  of  such  a  device  for  pur- 
poses of  examination,  even  after  one  is  familiar  with  the  use 
of  the  head  mirror. 

The  objection  to  a  mirror  of  large  diameter  lies  in  the 
fact  that  when  the  central  perforation  is  used,  the  border  of 
the  mirror  Iving-  close  to  the  uncovered  eve  interferes  with 


82 


PHYSICAL    EXAMINATION. 


the  perfect  relaxation  of  the  organ.  This  constitutes  a  source 
of  eye  strain,  and  after  the  instrument  has  been  worn  for  sev- 
eral hours  considerable  discomfort  is  occasioned. 

Regarding  binocular  inspection  of  the  parts,  it  is  mani- 
festly impossible  to  view  so  small  an  object  as  the  membrana 
tympani,  with  both  eyes  through  a  narrow  canal,  since  the 
length  of  the  canal  and  the  small  diameter  of  the  entrance  of 
the  meatus  would  render  it  necessary  to  have  the  examiner  sa 
far  away  from  the  object  to  be  examined,  that  the  exact  struc- 
ture could  be  seen  no  longer.  The  eye  not  in  use  should  be 
completely  relaxed,  and  the  beginner  should  under  no  cir- 
cumstances close  it,  as  the  muscular  exertion  which  this  en- 
tails becomes  a  source  of  great  discomfort  after  a  compara- 
tively short  time.  When  the  examiner  is  accustomed  to 
make  use  of  the  central  perforation  in  the  mirror,  and  desires 
to  use  an  incandescent  light,  this  may  be  arranged  upon 
a  standard  as  shown  in  ¥ig.  28,  the  rays  from  the  lamp 
being  reflected  into  the  canal  in  the  same  manner  as  when 
any  other  source  of  illumination  is  employed.  The  focal 
length  of  the  condensing  lens  under  such  circumstances  is  a 

matter  of  great  im- 
portance ;  its  focal 
distance  should  be 
such  that  the  rays 
are  rendered  parallel 
or  slightly  divergent 
when  they  strike  the 
mirror.  If  conver- 
gent rays  fall  upon 
the  reflecting  surface,^ 
the  result  will  be  that 
the  light  will  be 
brought  to  a  focus 
at  a  point  within  the 
true  focal  distance  of 
the  mirror,  beyond 
which  point  they  will 
again  diverge,  and 
the  illumination  of  the  parts  will  be  imperfect  unless  the  head 
is  brought  so  close  to  the  ear  as' to  render  instrumentation 
within  the  canal  impossible.  Some  prefer  to  wear  the  in- 
candescent light  upon  the  forehead  (Fig.  33),  dispensing  with 


Fig.  33. — Electric  lamp  worn  upon   the  forehead. 


AURAL   SPECULA.  83 

tlie  head  mirror  entirclv,  the  rays  being  brought  to  a  focus 
upon  the  deeper  parts  within  the  canal  by  means  of  a  series 
of  lenses  of  proper  curvature.  Those  accustomed  to  the  use 
of  the  head  mirror  upon  the  forehead  will  find  no  difficulty 
in  this  method  of  examination.  Where  one  habitually  uses 
the  central  perforation  in  the  mirror,  the  instrument  being 
worn  oyer  one  eye,  considerable  practice  is  necessary  to  be- 
come expert  in  using  the  incandescent  light  directly.  This  is, 
in  a  measure,  overcome  by  making  use  of  a  device  consisting 
of  a  head  mirror,  to  the  periphery  of  which  a  small  incandes- 
cent light  is  attached  ;  a  metallic  reflector  and  shade  surround 
the  lamp  and  direct  the  luminous  rays  upon  the  surface  of  tiie 
mirror,  after  which  they  are  thrown  into  the  canal  in  the 
same  manner  as  when  a  stationary  lamp  is  used.  I  repeat 
here,  that  all  electric  apparatus  is  apt  to  be  capricious,  and 
that  it  is  well  in  operating  outside  of  a  hospital,  where  all 
appliances  can  be  obtained  at  a  few  moments'  notice,  to  be 
provided  with  another  source  of  light  in  case  of  accident  to 
the  incandescent  lamp.  For  my  own  use,  the  portable  stand- 
ard shown  in  Fig.  28  is  so  arranged  as  to  support  both  the 
incandescent  lamp  and  an  ordinary  gas-burner,  the  latter 
i)eing  cormccted  with  anv  convenient  gas  fixture  in  the 
room,  and  care  being  taken  to  have  it  in  perfect  working 
order  before  any  ()j)eration  is  begun.  The  knowledge  that 
an  accident  to  the  battery  or  lamp  will  not  prove  a  source 
of  annoyance  is  a  great  mental  satisfaction  to  the  operator. 

Aural  Specula. —  In  order  to  ins[)ect  the  dee{)er  [)arts  of 
the  meatus,  the  membrana  tympani,  and  the  tympanic  cavity, 
it  is  necessary  to  separate  the  walls  of  the  cartilaginous  canal, 
and  to  overcome  the  irregularities,  at  the  same  time  changing 
the  axis  of  this  tube  to  correspond  with  that  of  the  osseous 
meatus.  This  latter  object  is  attained  by  traction  upon  the 
auricle  in  a  direction  upward,  backward,  and  outward,  while 
the  walls  of  the  canal  are  at  the  same  time  separated  and 
maintained  in  a  position  by  the  aural  speculum.  These  in- 
struments may  be  made  of  hard  rubber,  metal,  or  even  of 
stiff  paper,  and  vary  in  shape.  Individual  choice  plays  a 
prominent  part  in  the  selection  of  the  particular  form  of 
instrument  to  be  employed,  but  certain  rules,  applicable  to  all 
instruments  of  this  character,  must  be  borne  in  mind.  The 
material  of  which  the  speculum  is  made  must  be  as  thin  as 
possible,  in  carder  io  secure  the  maximum  field  of  inspection  ; 


84 


PHYSICAL    EXAMINATION. 


many  of  the  instruments  sold  are  so  thick  and  heavy  that, 
although  the  outside  diameter  is  comparatively  large,  the 
calibre  is  verv  small,  and  when  the  meatus  is  narrow  an 
instrument  that  can  be  introduced  with  comfort  to  the  pa- 
tient yields  but  a  small  area  for  inspection.  Care  should 
be  taken  that  the  end  of  the  instrument  inserted  into  the 
meatus  has  a  perfectly  smooth  margin,  as  any  irregularity 
of  outline  is  sure  to  cause  discomfort  to  the  patient,  and  in 
children,  to  begin  with  an  unfortunate  accident  of  this  kind 
may  render  an  examination  almost  impossible.  The  length 
of  the  speculum  is  also  a  matter  to  demand  attention.  It 
is  essential  that  the  instrument  shall  project  no  farther  be- 
yond the  entrance  of  the  meatus  than  is  necessary  to  per- 
mit of  its  being  lirmlv  held,  since  the  difificulty  of  examina- 
tion becomes  greater  when  the  observer  is  obliged  to  direct 
the  light  through  a  long,  narrow  passage  to  illuminate  a 
small  area  at  its  extremitv,  and  at  the  same  time  recognize 
minute  variations  in  the  condition  of  the  parts.  Under  the 
most  favorable  circumstances  the  meatus  itself  presents  ob- 
stacles which  render  an  exact  interpretation  of  the  conditions 
observed  verv  difficult,  and  to  increase  the  length  of  the 
passage  is  to  add  greatly  to  these.  The  speculum  should 
be  just  long  enough  to  allow  the  surgeon  to  hold  it  firmly 
when  in  position  and  no  longer.  It  is  also  important  that 
the  portion  of  the  tube  introduced  into  the  canal  should 
taper  slightly,  since  the  deeper  parts  are  less  distensible  than 
those  more  superficially  placed,  and  if  the  speculum  fills  the 
canal  C()m]->lctelv  it  can   not   be  tilted  in  diffcM-ent  directions, 


or)  r-. 


Fig.  34. — I'olitzei's  hard  rubber 
.luial  speculum. 


000 


Fig.  35. — Wilde'.-,  aural 
speculum. 


SO  as  to  bring  the  various  portions  of  the  fundus  into  view. 
The  exact  shape  is  unimportant ;  some  examiners  prefer  an 
instrument  the  orifice  of  which  is  circular  in  outline,  while 
others  advise  that  it  be  oval,  corresponding  in  form  to  the 
lumen  of  the  canal  as  seen  in  cross  section.     The  instrument 


AURAL    SI'ECULA. 


85 


bearing  the  name  of  Wilde  is  conical,  and  Uie  orifice  circular, 
while  in  Gruber's  speculum  the  tube  is  oval  on  cross  section, 
and  instead  of  being  conical  is  somewhat  funnel-shaped.  This 
last  feature  is  observed  in  the  instruments  of  Trocltsch.  Bou- 
cheron,  Toynbee,  Politzer,  and  others.  Manv  prefer  a  single 
instrument  which  can  be  adjusted  to  the  lumen  of  anv  canal 
by  means  of  a  set  screw,  the  device  resembling  in  construe- 


poo 


ViG.  30. — Gruber's  aural  specu- 
lum. 


Fig.  37. — Toynhee's  aural  specula. 
(The  inslniments  are  too  long,  and 
the  cut  is  introduced  to  show  this.) 


lion  the  bivalve  speculum  of  the  rhinologist.  in  some  in- 
stances it  is  advantageous  to  have  one  wall  of  the  tube  cut 
away  for  a  certain  distance  in  order  that  the  meatus  may  be 
inspected  after  the  instrument  has  been  inserted.  This  end  is 
best  accomplished  by  emploving  a  wire  speculum,  the  walls 
of  the  meatus  being  sei)aratcd  by  the  elasticitv  of  the  mate- 
rial of  which  it  is  constructed.  In  an  emergency  a  verv  serv- 
iceable speculum  can  be  made  with  a  piece  of  stifT  note  paper, 
twisted  into  the  form  of  an  elongated  cone,  the  free  edges  of 
the  paper  being  secured  by  a  pin,  a  stitch,  or  by  mucilage. 
This  cone  is  then  cut  ofT  at  such  a  distance  from  the  apex  as 
will  allow  it  to  be  easily  inserted  into  the  meatus,  while  in 
the  other  direction  it  is  so  cut  as  to  reduce  it  to  a  proper 
length.  Such  an  improvised  instrument  answers  perfectly  well 
not  only  for  diagnosis,  but  also  for  operative  purposes.  In 
fact,  I  frequently  use  them  in  preference  to  metal  specula,  even 
when  the  latter  are  at  hand.  Their  chief  advantage  is  their 
cleanliness,  the  same  cone  never  being  used  a  second  time. 

Whatever  form  of  speculum  may  be  chosen,  attention  to 
the  above  points  will  result  in  the  selection  of  a  serviceable 
instrument.  Exact  shape  is  immaterial,  as  constant  use  will 
soon  enable  the  surgeon  to  become  expert  with  any  one  of  the 
various  varieties.  One  possible  advantage  possessed  by  the 
funnel-shaped  instruments,  in  which  the  outer  opening  is  very 
wide,  is  that  the  examiner  can  more  easily  direct  the  light 
into  the  speculum  than  when  the  smaller  instrument  of  Wilde 


86  PHYSICAL    EXAMINATION. 

is  used.  Whether,  the  interior  of  the  instrument  is  polished 
or  blackened  also  depends  upon  individual  preference.  The 
contrast  of  the  black  background  mav  be  an  advantage,  but  a 
certain  amount  of  brilliancy  of  illumination  is  sacrificed. 

It  is  necessary  to  be  provided  with  specula  of  various  sizes, 
and  at  least  three  are  necessary  to  meet  the  differences  in 
diameter  of  the  orifice  of  the  meatus,  while  five  or  six  sizes 
are  still  more  advantageous.  The  proper  diameter,  accord- 
ing to  Richards,*  of  the  smaller  end  of  each  speculum  in  a 
set  of  five  of  the  Wilde  pattern  is  given  below,  and  will  be 
found  valuable;  7  mm..  6  mm.,  4*66  mm.,  4  mm.,  V5  nim. 

Being  provided  with  a  satisfactory  source  of  light,  a 
proper  head  mirror,  and  a  suitable  speculum,  the  next  step 
will  be  the  technique  of  the  examination. 

The  Technique  of  Examination  (F"ig.  38). — The  patient  and 
examiner  mav  both  be  seated,  a  jx^sition  which  1  decidedly 
prefer,  or  both  may  stand,  or  tb.e  patient  may  sit  while  the  phy- 
sician remains  standing.  The  patient  is  best  seated  in  a  high- 
backed  chair,  in  an  attitude  which  can  be  maintained  for  some 
time  without  discomfort,  the  head  resting  against  the  back  of 
the  chair,  the  affected  ear  being  turned  toward  the  examiner. 
The  surgeon,  either  sitting  or  standing,  should  occupv  a  posi- 
tion to  the  right  of  the  patient  rather  than  directly  facing  the 
affected  side.  Sitting  or  standing,  this  latter  position  must 
be  an  awkward  one,  and  in  the  event  of  the  examiner  prefer- 
ring to  remain  seated,  necessitates  the  separation  of  his  knees 
widely,  so  that  the  chair  of  the  patient  is  between  them. 
This  posture  is  not  only  uncomfortable,  but  for  obvious  rea- 
sons undesirable.  Moreover,  the  operator  is  not  able  to  fol- 
low any  sudden  motion  of  the  patient's  head  when  seated  in 
this  manner,  since  he  is  working  at  arm's  length.  When  the 
other  position  is  employed,  a  slight  motion  of  the  arm  enables 
the  operator  to  so  follow  anv  sudden  movement  which  the 
patient  may  make  on  account  of  fear  or  pain  that  the  exact- 
ness of  the  manipulation  is  in  no  way  disturbed. 

The  light  should  be  placed,  preferably,  on  the  left  of  the 
examiner,  and  slightly  above  the  horizontal  plane  passing 
through  the  ear  to  be  examined.  In  this  manner  any  ma- 
nipulation of  instruments  with  the  right  hand  will  not  inter- 
fere with  the  rays  passing  from  the  lamp  to  the  mirror. 

*  Burnett's  .System  of  Diseases  of  the  Ear,  Nose,  and  Throat,  1893,  vol.  i,  p.  105. 


TFXHNIQUE   OF    EXAMINATION. 


87 


The  patient,  surjj^eon,  and  source  of  light  being  satisfac- 
torily arranged,  it  should  be  the  invariable  rule  to  examine 
the  auricle,  the  entrance  of  the  meatus,  and  the  cartilaginous 
canal  to  as  great  a  depth  as  possible  before  the  speculum  is 
introduced,  as  the  speculum  mav  conceal  some  pathological 
condition  at  the  very  entrance  of  the  meatus  unless  this  rule 
is  followed.  In  order  to  examine  the  cartilaginous  canal  and 
to  prepare  for  the  insertion  of  the  speculum,  the  auricle  should 
be  grasped  firmly  but  lightly  at  its  upper  and  posterior  mar- 
gin between  the  third  and  fourth  fingers  of  the  left  hand,  and 


Fig.  3''-  1  ''<-■  ">.uuir  iiin|h-iuimi  hi  tm:  luiiiir ii .lu.i  I >  ii[|).iiii.  -ii'imim^  tlic  position  of 
the  patient,  the  surgeon,  the  source  of  light,  and  the  manner  of  holding  the 
speculum. 

traction  sh(juld  be  made  uj)ward,  backward,  and  outward.  In 
examining  the  right  ear  the  hand  lies  behind  the  auricle ;  in 
examining  the  left  ear  it  lies  above  apd  anterior  to  it.  In  this 
manner  a  fairly  good  view  of  the  external  portion  of  the  meatus 
is  obtained,  and  any  irregularities  in  size  and  shape  may  be 
noted  as  well  as  any  deviation  from  the  usual  direction.  The 
information  thus  derived  enables  the  investigator  to  select  a 
speculum  of  appropriate  size,  which  should  be  grasped  lightly 
between  the  thumb  and  index  finger  of  the  left  hand,  warmed 
over  the  lamp,  and  then  introduced  into  the  canal  as  lightly 
as  possible.  To  effect  this  the  operator  holds  the  speculum 
between  the  thumb  and   index   finger,  grasping  the  auricle, 


g8  PHYSICAL    EXAMINATION. 

as  before,  between  the  third  and  fourth  fingers  of  the  left 
hand.  While  the  auricle  is  drawn  upward,  outward,  and 
backward,  the  dilating  instrument  is  gently  introduced  into 
the  meatus,  is  advanced  gradually  by  rotation  upon  its  long 
axis,  it  being  rolled,  so  to  speak,  between  the  thumb  and  index 
finger,  while  at  the  same  time  it  is  pushed  inward.  Care  should 
be  taken  not  to  pass  the  instrument  beyond  the  cartilagi- 
nous canal,  since  this  is  not  only  painful,  but  interferes  with 
the  mobilitv  of  the  outer  portion  of  the  meatus,  and  hence 
limits  the  area  exposed  for  inspection.  The  speculum  must 
be  of  such  a  size  that  the  walls  of  the  canal  are  simjily  sepa- 
rated by  it  and  not  stretched,  as  this  interferes  with  the  mo- 
bility of  the  membranous  portion  of  the  canal  and  prevents 
it  being  so  manipulated  as  to  make  its  axis  coincide  with 
that  of  the  bony  meatus.  When  the  speculum  is  too  large 
the  soft  parts  are  so  crowded  in  front  of  it  that  the  full  lumen 
of  the  speculum  is  not  available  and  the  field  is  narrowed  in 
consequence. 

The  speculum  having  been  properly  inserted,  the  observer 
should  first  bring  that  part  of  the  superior  wall  of  the  canal 
into  view  which  lies  just  beyond  the  inner  extremity  of  the 
speculum.  This  is  done  bv  carrying  the  thumb  and  index 
tinjrer  which  hold  the  instrument  downward,  thus  tiltins:  the 
inner  extremity  ui)ward.  Having  recognized  the  superior 
wall  of  the  meatus,  the  anterior,  inferior,  and  posterior  walls 
are  successively  brought  into  view  bv  causing  the  outer  end 
of  the  speculum  to  describe  a  circle  in  the  direction  named, 
the  fixed  point  being  the  inner  extremity  of  the  instrument. 
This  manipulation  is  accomplished  by  a  slight  movement  of 
the  thumb  and  finger  which  grasp  the  outer  end  of  the  specu- 
lum, the  digits  being  alternately  flexed  and  then  gradually 
extended  until  the  extremity  of  the  instrument  has  described 
a  complete  circle.  In  conducting  this  manipulation  each 
wall  of  the  meatus  should  be  inspected  throughout  its  entire 
extent,  from  the  inner  end  of  the  speculum  to  where  it  joins 
the  tympanic  ring. 

Attention  should  be  paid  during  this  procedure  to  the  fol- 
lowing points  regarding  the  canal :  Whether  it  is  free  through- 
out its  entire  length,  or  partially  or  completely  obstructed. 
If  the  lumen  is  encroached  upon,  information  should  be  ob- 
tained as  to  the  nature  of  the  obstruction,  whether  it  be  a  for- 
eiirn  body  accidentally  or  intentionally  introduced,  or  whether 


TECHNIQUK    OF    EXAMINATION.  89 

it  is  made  up  of  a  mass  ul  impacted  secretion,  whose  source 
is  the  ceruminous  glands  of  the  meatus,  or  of  epithelial  debris, 
the  result  of  an  inflammatory  process,  or  of  a  parasitic  growth 
which  has  proliferated  in  this  locality.  On  the  other  hand, 
the  deeper  portion  of  the  canal  may  be  filled  with  fluid,  either 
pus,  serum,  mucus,  or  blood.  Again,  the  lumen  of  the  canal 
may  be  encroached  upon  only  oyer  a  certain  circumscribed 
area,  in  which  case  the  probe  determines  the  density  of  the 
obstruction — whether  it  is  hard  or  soft,  tender  or  anaesthetic, 
whether  inyested  with  normal  epithelium  or  presenting  a  de- 
nuded surface.  Its  location  should  always  be  carefully  noted, 
whether  it  is  situated  in  the  deeper  portion  of  the  canal  or 
near  the  orifice.  In  other  cases  the  canal  may  be  narrowed 
uniformly  throughout  its  entire  extent.  Here  the  density  of 
the  walls  as  determined  by  the  probe  is  of  seryice,  as  well  as 
the  appearance  ot  the  outer  surface.  None  of  these  more  eyi- 
dent  abnormal  conditions  e.xisting,  the  obseryer  should  in  all 
cases  note  the  condition  of  the  integument  lining  the  canal, 
determining  whether  it  is  dry  and  desijuamating  in  jdaces,  or 
moist  and  reddened,  or  coycrcd  here  and  there  with  masses  of 
dry  secretion  forming  crusts  upon  the  walls.  Haying  critic- 
ally observed  these  different  physical  conditions,  the  suj)erior 
wall  of  the  meatus  should  be  followed  inward,  the  angle  of 
the  speculum  being  gradually  changed  so  as  to  bring  the 
deeper  portions  into  view  until  this  aspect  of  the  canal  merges 
into  the  membrana  flaccida.  The  outer  end  of  the  speculum 
being  still  further  elevated,  the  eye  next  recognizes  the  epi- 
dermal covering  of  the  membrana  tympani  and  follows  this 
until  it  passes  quite  abru[)tly  into  the  inferior  wall  of  the 
meatus.  .\n  examination  in  this  manner — the  superior  wall 
being  followed  across  the  fundus  of  the  meatus  until  the  eve 
h^oks  upon  the  inferior  wall,  and  the  posterior  wall  traced 
until  it  merges  without  a  break  into  the  anterior — demonstrates 
with  certainty  that  the  membrana  tvmpani  is  {present,  and.  if 
no  s(jlution  in  continuity  has  been  observed,  intact.  This  is 
the  most  satisfactory  method  of  demonstrating  that  the  mem- 
brana tympani  is  present  and  unbroken  throughout  its  entire 
extent.  Whenever  there  is  a  solution  of  continuity  this  regu- 
lar outline  must  be  broken.  In  some  cases,  where  the  mem- 
brane is  almost  completely  destroyed  and  is  replaced  by  cica- 
tricial tissue  which  applies  itself  closely  to  the  internal  wall  of 
the  tympanum,  a  mistake  may  be  made  ;  this  is  scarcely  pos- 


90 


PHYSICAL    EXAMINATION. 


sible,  however,  if  an  exhaustive  examination  is  made,  each 
wall  being-  followed  until  it  merges  into  the  one  directly  op- 
posite. When  the  membrana  is  extensively  destroyed,  as 
mentioned  above,  we  find  usually  at  some  point  along  the 
posterior  wall  that  the  fundus  of  the  canal  is  not  continuous 
with  this  wall,  but  that  there  is  a  solution  of  continuity  at  the 
inner  extremity,  the  epidermis  not  passing  directly  from  the 
posterior  wall  of  the  canal  to  the  promontory,  but  that  a  cer- 
tain space  is  left  be<^ween  these  two  regions,  the  width  of  the 
hiatus  being  easily  recognized  by  the  practiced  eye.  I  have 
given  this  as  one  of  the  early  steps  in  conducting  the  examina- 
tion, since  the  observer  more  readily  analyzes  appearances 
met  with  if  the  question  of  presence  or  almost  complete  de- 
struction of  the  drum  membrane  has  been  settled  before  other 
points  are  considered. 

We  must  next  recognize  certain  landmarks  at  the  fundus 
of  the  canal,  which  under  normal  conditions  is  occupied  by 
the  membrana  tympani  {Fig.  39).  As  the  superior  wall  is  fol- 
lowed inward,  there  will  be  seen  just  below  the  centre  of  the 
line  marking  its  inner  termination,  a  prominent  projection, 
white  or  grayish  white  in  color,  having  the  appearance  as 
though  the  soft  parts  covering  it  were  pushed  outward  into 
the  lumen  of  the  canal  by  some  firm  body  beneath.  This  pro- 
jection is  the  short  process  of  the  malleus,  and  its  position 
changes  but  little,  no  matter  how  much  the  entire  ossicle  mav 
be  displaced  bv  rotation  about  the  axis  from  alterations  in 
tension  of  the  intratympanic  ligaments  and  muscles.  More- 
over, this  portion  of  the  ossicle  is  richlv  supplied  with  nutrient 
vessels,  and  even  when  there  is  extensive  caries  of  the  tym- 
panic walls  and  of  the  ossicular  chain,  it  usually  escapes  dis- 
integration. Under  normal  conditions  the  short  process  of 
the  malleus  appears  as  a  prominent  point,  about  the  size  of  a 
pinhead,  varying  in  color  from  a  chalky  white  to  a  grayish 
white  or  even  pinkish  white.  Extending  downward  and  some- 
what backward  from  this  point,  through  the  middle  of  the 
membrane  as  far  as  its  centre,  the  handle  of  the  malleus  is 
recognized.  This  process  tapers  gradually  as  it  passes  down- 
ward. At  its  lower  extremity  it  is  flattened  slightlv  from 
without  inward,  and  appears  a  little  broader  than  just  above 
its  termination.  The  shaft  of  the  malleus  is  slightly  curvi- 
linear in  outline,  the  convexity  being  toward  the  meatus  in 
the  upper  two  thirds,  while  at  the  lower  third  it  is  directed 


THE    MEM  BRAN  A     TYMl'ANI. 


9» 


inward  and  somewhat  backward,  lying  more  nearly  in  the 
plane  of  the  membrane.  The  outline  of  the  shaft,  under  normal 
conditions,  appears  somewhat  darker  than  the  surrounding 
membrane,  its  presence  offering  an  obstruction  to  the  ravs  of 
light  illuminating  the  fundus  of  the  canal.  The  outline  of  the 
shaft  is  not  infrequently  slightly  pinkish  instead  of  white,  and 
occasionally  one  or  two  blood  vessels  may  be  recognized  trav- 
ersing the  membrane  close  to  the  manubrium  and  parallel  to 
it.  This  is  particularly  true  if  the  speculum  has  remained  in 
the  canal  for  some  time,  and  depends  upon  the  venous  con- 
gestion incident  to  the  presence  of  the  foreign  body.  The 
flattened  termination  of  the  manubrium  at  the  centre  of  the 
membrane  is  known  as  the  umbo.  Under  normal  conditions 
the  eye  perceives  a  bright  triangular  area  upon  the  surface  of 
the  membrane,  extending  from  the  umbo  downward  and  for- 
ward to  the  periphery,  the  apex  of  the  triangle  Iving  at  the 
umbo,  while  the  base  of  the  triangle  does  not  extend  to  the 
periphery,  but  fades  away  gradually  before  it  reaches  this 
line.  It  is  evident  that  if  we  imagine  the  malleus  handle  to 
be  prolonged  to  the  periphery  of  the  membrane,  this  struc- 
ture will  be  divided  into  two  portions — one  in  front  and 
the  other  behind  the  line,  the  j)Ostcrior  portion  being  the 
larger.  If  a  h(jrizontal  line  is  drawn  through  the  umbo  to  the 
anterior  and  posterior  walls  of  the  canal,  these  two  segments 
will  be  again  divided  into  two.  For  convenience  in  locating 
pathological  appearances  we  conceive  the  drum  membrane  to 
be  so  divided,  the  segments  being  named  the  superior  anterior, 
inferior  anterior,  inferior  posterior,  and  sui)crior  posterior 
quadrants  according  to  their  situation.  From  the  short  pro- 
cess of  the  malleus  two  bands  are  observed, 
one  running  backward,  the  other  in  the  op- 
posite direction,  t(^  the  peripherv  of  the 
membrane.  Of  these,  the  posterior  is  the 
longer,  the  anterior  being  just  barely  seen 
under  normal  conditions  owing  to  the  prox- 
imity of  the  short  process  of  the  malleus  to  f,g.  39 —The  normal 
the  upper  anterior  extremity  of  the  tym-        membrana  tympani 

.  .  ,,  ,,..  (somewhat  diagram- 

panic    rmg,   and   because    of   the   obliquity        matic). 

of  the  plane  in  which  the  membrane  lies. 

These  bands  are  called  the  anterior  and  posterior  folds  of  the 

membrane.      They  are   caused   by   the   difference  in   tension 

between  the  membrana  tensa  below  and  the  membrana  flac- 


92  PHYSICAL    EXAMINATION. 

cida  above.  These  bands  are  sometimes  very  well  marked, 
while  in  other  instances  thev  are  not  distinct. 

Between  the  short  process  of  the  malleus  and  the  superior 
wall  of  the  meatus  the  membrana  tvmpani  presents  a  distinctly 
triangular  form,  the  apex  of  the  triangle  Iving  at  the  short 
process,  from  which  point  the  sides  of  the  triangle  diverge 
until  they  are  lost  in  the  superior  wall  of  the  canal,  into 
which  they  pass  without  any  distinct  line  of  demarcation.  The 
sides  of  the  triangle  are  clearly  marked  by  a  thickening  along 
the  lateral  boundaries  of  this  triangular  area.  This  upper 
portion  of  the  drum  membrane  is  the  membrana  flaccida,  or 
Shrapnell's  membrane,  and  the  fibres  w-hich  form  the  sides 
of  the  triangle  are  known  as  Prussak's  fibres.  It  will  be  re- 
membered that  the  tvmpanic  ring  is  wanting  at  Shrapnell's 
membrane,  the  curvilinear  outline  being  completed  by  the 
free  border  of  the  outer  lamella  of  the  squamous  plate  of  the 
temporal  bone,  which  fills  up  the  gap  between  the  anterior 
and  posterior  limbs  of  the  annulus.  The  name  of  Rivinian 
fissure  or  segment  has  been  given  to  this  dehiscence  in  the 
annulus  tympanicus.  It  is  also  to  be  borne  in  mind  that  the 
lamina  propria  of  the  drum  membrane  is  wanting  over  this 
area,  the  septum  being  comp)letcd  by  the  tegumentary  lining 
of  the  canal  which  passes  downward  over  the  Rivinian  fis- 
sure, its  epithelial  layer  being  continued  over  the  surface  of 
the  membrana  tympani. 

Having  determined  that  the  membrana  tympani  is  intact, 
or,  if  any  solution  of  continuity  exists,  the  extent  and  location 
of  the  defect  having  been  made  out,  the  observer  should  next 
note  the  following  physical  properties  of  the  membrana  or  of 
its  remaining  portion  :  i.  The  color.  2.  The  lustre.  3.  The 
structure.     4.  The  position. 

The  Color. — The  normal  membrane  is  of  a  pearly-white 
appearance,  with  a  slightly  bluish  tinge  over  the  entire  mem- 
brana tensa  ;  above  the  folds  the  parts  ma}'  have  a  faint  ])ink- 
ish  hue,  even  when  in  a  healthy  condition. 

The  Ljtstre. — The  recognition  of  variations  in  the  lustre  of 
the  drum  membrane  constitutes  one  of  the  most  valuable  aids 
in  the  diagnosis  of  aural  affections.  Normally  the  parts  pos- 
sess a  peculiar  sheen  which  can  not  be  described  in  words, 
but  is  easily  recognized  when  once  seen.  The  triangular  light 
spot  has  already  been  spoken  of,  and  its  persistence  or  ab- 
sence, the  variations  in  shape,  position,  and  e:  tent,  and  the 


THE    MEMBRANA    TV.Ml'ANJ.  93 

presence  of  one  or  more  brii^ht  points  or  light  reflexes  in  ollicr 
parts  of  the  membrane,  all  furnish  valuable  information.  The 
lustre  may  be  diminished  or  mav  be  entirely  wanting,  this 
latter  condition  always  indicating  a  necrosis  of  the  superficial 
epithelium. 

The  Structure. — Under  this  term  we  consider  the  devia- 
tions from  the  normal  appearance  resulting  from  changes  in 
the  various  layers  of  the  part  under  examination.  In  health 
the  membrana  vibrans  is  of  uniform  texture  throughout,  ex- 
cept at  the  periphery  and  at  the  umbo,  in  which  localities  it 
is  somewhat  thickened  and  consequently  less  translucent  than 
elsewhere.  The  eve  is  also  able  to  make  out  indistinctly  the 
circular  and  radiating  fibres  as  they  cross  one  another,  giving 
an  appearance  suggestive  of  a  finely  woven  fabric.  Under 
[tathological  conditions  the  membrana  propria  may  undergo 
hypertrophy  in  places,  in  which  case  the  uniformity  of  tex- 
tural  appearance  will  be  lost  and  the  affected  areas  will  appear 
less  translucent  than  the  surrounding  ])orti()n.  The  same  ef- 
fect is  produced,  but  in  a  more  marked  degree,  by  calcareous 
deposits  in  the  fibrous  layer.  These  appear  as  opaque,  lustre- 
less white  areas,  with  well-defined  outlines.  On  the  other  hand, 
as  the  result  of  pressure,  cicatrization  after  loss  of  substance, 
etc.,  the  fibrous  layer  may  be  very  thin  or  even  wanting  in 
certain  localities.  Here  the  membrane  will  be  transparent,  and 
through  the  thin  septum  the  underlying  structures  within  the 
tympanum  mav  be  easily  recognized.  The  membrana  tlaccida, 
containing  no  lamina  propria,  does  not  exhibit  the  peculiar 
woven  ap])carance  characteristic  of  the  larger  segment  of  the 
drum  membrane  ;  its  appearance  is  similar  to  that  of  the  skin 
lining  the  adjacent  part  of  the  bonv  meatus,  except  that  it  is 
more  delicate  in  structure.  Owing  to  ])athological  changes 
it  may  become  transparent  and  parchmentlike,  or  its  thick- 
ness may  be  greatly  increased. 

The  Position. — Normally,  the  drum  membrane  is  inclined 
both  in  the  horizontal  and  vertical  planes.  In  addition  to  this 
it  is  drawn  inward  at  the  umbo  on  account  of  its  intimate  con- 
nection with  the  manubrium  mallei.  The  inclination  in  two 
planes,  together  with  the  umbilication  at  the  centre,  gives  rise 
to  the  light  reflex,  the  rays  illuminating  this  area  alone  be- 
ing reflected  directly  back  to  the  eye  of  the  observer,  without 
previously  impinging  upon  the  walls  of  the  canal.  Another 
result  of  the  umbilication  is  to  sive  to  each  segment  of  the 


94 


PHYSICAL    EXAMINATION. 


membrana  a  slightly  convex  appearance  when  viewed  from 
the  canal,  which  is  most  marked  in  the  upper  and  posterior 
quadrants.  In  the  young  child  the  inclination  of  the  mem- 
brane in  the  horizontal  plane,  as  viewed  through  the  meatus, 
appears  more  pronounced  than  in  adult  life.  This  greater  in- 
clination is  more  apparent  than  real.  dej)ending  upon  the  spe- 
cial conformation  of  the  parts  at  birth.  At  this  period,  it  will 
be  remembered,  the  superior  and  inferior  walls  of  the  meatus 
are  in  contact,  the  superior  wall  lying  upon  the  external  sur- 
face of  the  squama  while  the  bony  meatus  does  not  exist,  be- 
ing represented  by  a  canal  of  fibrous  tissue,  especially  well 
developed  along  the  inferior  wall. 

Having  reviewed  the  appearance  of  the  membrane  under 
normal  conditions,  we  are  now  prepared  to  recognize  varia- 
tions caused  by  morbid  processes.  As  the  upper  and  posterior 
part  is  nearest  the  eve  of  the  observer,  and  as  this  is  the  most 
extensive  segment  of  the  membrane,  displacement  of  the  entire 
membrane  outward  in  this  region  is  more  apparent  than  else- 
where. If  displacement  be  excessive  the  bulged  posterior  por- 
tion may  overhang  the  anterior  segment  and  partially  or  com- 
pletely obscure  it.  Sometimes  the  effect  is  to  obliterate  in  this 
region  the  line  of  demarcation  between  the  canal  wall  and  the 
drum  membrane,  giving  to  the  fundus  a  narrow  appearance. 
On  the  other  hand,  marked  retraction  obliterates  the  normal 
prominence  of  the  upper  and  posterior  segment  and  exagger- 
ates the  inclination  of  the  upper  part  of  the  membrane  in  the 
horizontal  plane,  at  the  same  time  causing  the  inferior  segment 
to  appear  more  nearly  perpendicular  to  the  inferior  wall  of  the 
canal.  It  also  tends  to  exaggerate  the  apparent  width  of  the 
drum  membrane  on  account  of  the  greater  depth  of  the  tym- 
panum above  and  behind,  which  allows  the  membrana  to  move 
inward  for  a  considerable  distance,  thus  bringing  the  anterior 
segment  into  view.  As  seen  through  the  speculum,  this  in- 
crease in  the  transverse  diameter,  especially  of  the  inferior 
segment,  is  exceedingly  well  marked.  The  most  valuable  in- 
dication of  retraction,  however,  is  afforded  by  a  careful  inspec- 
tion of  the  malleus  handle.  This  prominent  and  easily  recog- 
nizable landmark  appears  foreshortened  in  direct  proportion 
to  the  degree  of  retraction,  provided  adhesions  between  it  and 
the  inner  tympanic  wall  do  not  exist,  and  prevent  it  from  as- 
suming the  usual  position  which  it  occupies  when  the  pressure 
within  the  tympanic  cavity  is  lowered.     Another  evidence  of 


OBSTACLES    TO    EXAMINATION.  95 

extreme  retraction  is  the  prominence  of  the  curved  margin  of 
the  tympanic  ring,  which  can  frequently  be  traced  throughout 
its  entire  circumference  when  the  membrane  is  displaced  in- 
ward to  a  marked  degree.  It  sometimes  happens,  owing 
to  the  presence  of  adhesions,  that  the  handle  of  the  malleus  is 
not  foreshortened ;  then  the  displacement  of  the  segments  of 
the  drum  membrane  in  front  and  behind  the  manubrium,  to- 
gether witli  the  marked  prominence  of  the  annulus  and  the 
ease  with  which  the  intratvmpanic  structures  are  seen,  enable 
the  observer  to  interpret  the  condition  correctly.  When  the 
malleus  handle  is  rtrmly  bound  down  and  the  air  within  liic 
tvmpanic  cavitv  is  rarefied,  the  anterior  and  j)osterior  seg- 
ments of  the  drum  membrane  collapse,  and  the  manubrium 
appears  as  a  prominent  ridge  between  the  sunken  areas.  In 
front,  behind,  and  below  this  ridge  there  are  dccj)  pits  or  fossae, 
where  the  more  elastic  membrane  has  been  forced  inward  by 
the  pressure  of  the  air  until  it  has  impinged  upon  the  inner 
tvmpanic  wall,  in  children  this  condition  is  very  prone  to 
exist  where  adenoid  vegetations  are  present.  The  appearance 
is  not  infrequently  a  source  of  error  in  diagnosis,  being  mis- 
taken for  a  total  destruction  of  the  membrana  vibrans  and 
a  subsecjucnt  dermoid  transformation  of  the  inner  tympanic 
wall. 

Obstacles  to  the  Examination. — The  description  given  of 
the  teciinitiue  of  the  in^i)eclit»n  of  the  ear  by  means  of  re- 
flected light,  presupposes  that  an  unimpeded  view  has  been 
j)0ssible;  occasionally,  however,  obstacles  are  encountered 
which  render  the  insj)ectit)n  of  the  deeper  j)arts  difficult 
I  lere  we  mav  mention  the  presence  of  fine  hairs  in  the  meatus 
preventing  a  perfect  illumination  of  the  membrana  tympani. 
In  such  an  event  the  examiner,  after  the  insertion  of  the 
speculum,  will  find  it  advisable  to  apply  a  little  vaseline  or 
wax  to  the  hairy  area  bv  means  of  a  cotton-tipped  probe  ;  by 
this  procedure  the  hairs  are  made  to  adhere  closely  to  the 
wall  of  the  canal,  and  are  prevented  from  interfering  with 
the  examination.  If  the  orifice  of  the  meatus  is  exceedingly 
narrow,  either  as  the  result  of  congenital  malformation,  cica- 
tricial contraction,  or  an  acute  circumscribed  inflammatory 
process,  the  examiner  will  do  well  to  use  an  exceedingly 
small  speculum.  By  tilting  the  instrument  at  various  angles 
it  will  be  possible  to  inspect  the  deeper  parts  over  successive 
small  areas  until  the  necessary  informaticm  has  been  obtained. 


96  PHYSICAL   EXAMINATION. 

This  is  wiser  than  to  attempt  to  use  a  large  instrument  which 
fits  the  canal  closely,  in  the  hope  of  obtaining  a  more  ex- 
tended field  of  view. 

The  prominence  of  the  antero-inferior  wall  occasionally 
offers  an  obstacle  to  perfect  inspection  of  the  deeper  parts ; 
but  here  again  the  small  speculum  will  enable  the  observer 
to  see  a  more  extended  surface  than  a  larger  instrument, 
provided  the  auricle  is  drawn  upward  and  backward  suffi- 
ciently to  permit  the  illumination  of  the  parts  beyond  the 
obstructing  canal  wall.  In  the  same  manner,  if  the  orifice  of 
the  meatus  is  almost  closed,  as  the  result  of  an  acute  inflam- 
matory process,  and  the  parts  are  excessively  tender,  it  is  pos- 
sible, by  exercising  a  little  care,  to  introduce  a  small  specu- 
lum beyond  the  inflamed  area,  and  to  obtain  a  view  of  the 
deep  parts.  It  is  to  be  remembered  that  no  bony  meatus 
exists  at  birth,  and  the  membrana  tympani  lies  superficially 
and  in  nearly  the  same  plane  as  the  superior  wall  of  the  canal, 
which  is  closely  attached  to  the  outer  surface  of  the  squama; 
hence,  to  obtain  a  clear  view  of  the  membrane,  the  auricle 
must  be  drawn  downward  and  backward  instead  of  upward 
and  backward,  as  in  the  examination  in  an  adult  (Fig.  26). 

In  addition  to  what  has  already  been  said  concerning  the 
recognition  of  the  various  normal  and  pathological  condi- 
tions, it  is  necessary  to  call  attention  to  special  portions  de- 
manding particular  investigation ;  these  are  the  periphery 
of  the  membrane,  and  that  area  lying  above  the  level  of 
the  short  process,  the  membrana  flaccida.  It  is  quite  pos- 
sible to  recognize  all  the  conditions  enumerated  in  the  pre- 
ceding pages  and  yet  to  overlook  a  small  perforation,  unless 
the  examiner,  as  a  final  step,  inspects  the  entire  outline  of 
the  annulus,  following  with  the  speculum  the  line  of  attach- 
ment of  the  membrane  throughout  its  entire  circumference. 
Again,  that  region  situated  above  the  short  process  of  the 
malleus  and  the  folds  of  the  membrane  demands  careful  at- 
tention, since  it  covers  the  articulation  between  the  malleus 
and  the  incus,  and  that  portion  of  the  tympanum  where  the 
mucous  lining  is  thrown  into  numerous  folds  as  it  passes 
from  the  bonv  walls  of  the  cavity  over  the  intratympanic 
ossicles  and  ligaments.  It  is  not  uncommon  to  find  a  miimte 
perforation  through  the  membrana  flaccida,  which  might  pass 
unrecognized  unless  special  attention  had  been  directed  to 
the  inspection  of  this  locality.     It  should  be  borne  in  mind  in 


TYMPANIC    TOPOGRAPHY. 


97 


this  connection  that  we  occasionally  meet  with  a  minute  oj)en- 
ing,  just  above  the  short  process  of  the  malleus.  This  was 
formerly  supposed  to  be  occasioned  by  the  incomplete  closure 
of  the  Rivinian  segment.  A  small  opening  at  this  point  is, 
according  to  Randall,*  due  to  a  pathological  process,  and 
there  is  no  foundation  for  considering  it  a  result  of  im{)erfcct 
development.  Under  all  circumstances  both  cars  should  be 
examined,  althcnigh  the  patient  may  complain  of  but  one. 
The  importance  of  this  is  evident  if  the  reader  will  recall 
the  remarks  already  made  in  the  chapter  on  physiology,  con- 
cerning the  interdependence  of  one  organ  upon  that  of  the 
opposite  side.  It  is  also  important,  since  any  slight  anomaly 
in  the  direction  of  the  canal  or  in  the  position  of  the  mem- 
brana  tvmpani  will  probably  exist  on  both  sides,  and  a  source 
of  error  in  the  inter|)retation  of  appearances  found  in  the 
affected  organ  will  thus  be  removed. 

At  this  point  we  should  consider  the  relation  between  the 
contents  of  the  tympanum  and  the  various  (juadrants  of  the 
tympanic  membrane. 

Fig.  12  represents  the  intratympanic  structures  and  the 
inner  wall  of  the  middle  ear,  the  ossicles  lying  in  their  nor- 
mal position.  A  {)ortion  of  the  inferior  and  posterior  wall  of 
the  canal  is  shown.  The  membrana  tympani,  with  the  excep- 
tion of  a  small  cresccntic  portion  posteriorly,  has  been  re- 
moved and  the  contents  of  each  quadrant  can  be  easily  made 
out. 

In  the  supero-posterior  quadrant  the  long  process  of  the 
incus  is  seen  descending  in  a  direction  parallel  to  the  manu- 
brium mallei,  lying  behind  it  and  at  a  deejjer  level  in  the 
tympanic  cavity.  The  articulation  of  this  process  with  the 
head  of  the  stapes  is  also  seen,  together  with  the  posterior 
crus  of  this  latter  ossicle,  which  passes  upward  and  inward 
until  it  is  lost  in  the  oval  niche.  From  the  head  of  the  stapes 
a  delicate  fibrous  band  is  observed,  which  extends  directly 
backward  until  it  is  lost  from  view  behind  the  margin  of  the 
tympanic  ring.  This  is  the  tendon  of  the  stapedius  muscle. 
The  tip  of  the  descending  crus  of  the  incus  (and  hence  the 
incudo-stapedial  articulation)  may  frequently  lie  at  a  consid- 
erable distance  below  the  level  of  the  short  process  of  the 
malleus.     On  the  other  hand,  and  especially  as  the  result  of 

*  Trans  Am.  Otol.  Society,  1894. 


98  PHYSICAL    EXAMINATION. 

a  pathological  condition,  this  process  of  the  incus  may  run 
almost  horizontally  inward,  the  processus  lenticularis  being 
liidden  behind  the  supero-posterior  margin  of  the  bony  ring. 
In  such  an  event  the  stapes  itself  and  the  sta})edius  tendon  are 
out  of  the  range  of  vision.  Another  situation  frequently  oc- 
cupied by  this  process  of  the  incus  is  close  to  and  just  behind 
the  posterior  margin  of  the  bony  ring.  It  passes  downward 
in  a  direction  parallel  to  the  posterior  limb  of  the  annulus,  and 
is  brought  into  view  if  the  patient's  head  is  turned  away  from 
the  examiner,  permitting  the  illuminating  rays  to  pass  behind 
the  projecting  margin  of  the  ring.  This  position  of  the  incus 
is  usually  the  result  of  contraction  of  the  stapedius  muscle 
or  of  shortening  of  its  tendon.  Search  with  a  delicate  probe 
reveals  the  location  of  the  crus  of  the  incus,  the  instrument 
being  easily  hooked  about  it  and  drawing  it  into  view.  If 
Hrmly  fixed,  the  division  of  the  stapedius  tendon  or  of  dense 
adhesions  passing  backward  from  the  posterior  crus  of  the 
stapes  releases  it  and  brings  it  into  the  field  of  vision.  The 
upper  and  posterior  quadrant,  since  it  contains  structures  so 
im})ortant  to  the  function  of  audition,  should  always  be  closely 
examined,  whether  the  membrana  tympani  is  intact  or  par- 
tially destroyed.  Frequently  the  attenuation  of  the  mem- 
brana in  this  locality,  either  from  cicatrization  or  atrophy, 
enables  the  observer  to  recognize  the  above-mentioned  parts 
through  it.  This  is  particularly  so  when  there  is  consider- 
able retraction  of  the  drum  membrane,  which  then  applies 
itself  closely  to  the  structures  beneath. 

Below  the  incudo-stapcdial  articulation  in  the  lower  part 
of  the  supero-posterior  quadrant,  and  encroaching  to  a  greater 
or  less  extent  upon  the  postero-inferior  quadrant,  is  seen  a 
deep  niche  the  ])osterior  boundary  of  which  is  hidden  by  the 
margin  of  the  annulus  tympanicus,  while  the  anterior  mar- 
gin forms  the  postero-inferioi'  boundary  of  the  promontory. 
At  this  line  the  inner  tympanic  wall  bends  at  almost  a  right 
angle,  and  the  plane  of  the  niche  is  directed  backward  and 
downward.  The  depression  formed  by  this  sudden  bend  is 
the  niche  of  the  round  window.  Sometimes  it  lies  entirely 
behind  the  margin  of  the  ring  and  out  of  the  field  of  vision. 
The  portion  ol  the  tympanic  wall  occupying  the  middle  of 
the  field  of  inspection  is  the  promontory.  It  covers  the  first 
turn  of  the  cochlea,  and  exhibits  a  convex  surface  which  en- 
croaches to  a  varying  extent  upon  the  the  cavity  of  the  ty.m- 


TYM PANIC    TOPOGRAPHY.  99 

pnnum.  When  this  portion  of  the  wall  is  unusually  convex, 
and  the  niche  of  the  round  window  can  be  seen,  the  pro- 
jecting mass  will  occasionally  be  mistaken  for  an  exostosis 
unless  the  possibility  of  its  anomalous  prominence  is  borne 
in  mind.  The  region  corresponding  to  the  antero-inferior 
cpiadrant  presents  nothing  demanding  special  notice,  except 
that  the  tympanic  opening  of  the  Eustachian  tube  may  en- 
croach ufxin  its  upper  part.  In  the  majority  of  cases  the 
tympanic  orifice  of  the  tube  lies  in  the  upper  anterior  quad- 
rant and  may  be  entirely  concealed  by  the  anterit)r  border  of 
the  tympanic  ring. 

When  the  membrana  vibrans  is  absent  it  is  possible  to 
pass  a  delicate  probe,  bent  at  a  right  angle  at  the  tip,  upward 
into  the  yault  of  the  tympanum,  both  in  front  and  behind  the 
sh(irt  process  of  the  malleus,  the  angular  jiortion  (iisaj)j)ear- 
ing  completely  in  the  uj)per 
tympanic  space.  Traction 
outward  causes  the  bent  i»art 

of    the   j)robe    to    press  upon  ,.„.   ^o._Middic  car  piubc. 

the  inner  extremity  of  the  su- 
j)ciior  wall  of  the  canal,  and  the  instrununt  can  not  be  rc- 
moycd  by  traction  directly  outward,  it  being  necessary  first 
to  disengage  its  tympanic  extremity  from  the  inner  margin 
of  the  su])erior  wall  of  the  meatus. 

As  the  result  of  caries,  the  superior  wall  of  the  meatus 
close  to  the  tympanum  may  be  destroyed,  bringing  into  yiew 
a  portion  of  the  head  of  the  malleus  and  the  adjacent  part  of 
the  incus,  or,  where  the  ossicles  haye  been  destroyed  or 
displaced,  the  upper  part  of  the  inner  tympanic  wall  lies  ex- 
posed. We  then  see  distinctly  the  pclyis  oyalis,  and  just 
aboye  this  the  wall  of  the  aqua?ductus  Fallopii  arching  oyer 
it.  If  this  last  structure  has  been  inyohed  in  the  carious 
process,  impact  of  the  probe  may  cause  twitching  of  the 
facial  muscles,  owing  to  mechanical  irritation  of  the  seventh 
nerve. 

Naturally,  in  inspecting  the  tympanic  cavity  where  the 
membrana  tvmpani  has  been  destroyed  as  the  result  of  dis. 
ease,  or  whei'e  a  flap  has  been  reflected  for  the  purpose  of 
exploration,  the  parts  which  can  be  brought  into  view  will 
largely  depend  both  upon  the  position  in  which  the  head  of 
the  patient  is  placed  and  upon  the  correct  manipulation  of  the 
speculum,  so  that  areas  hidden  from  the  direct  line  of  vision 


lOO  PHYSICAL    EXAMINATION. 

by  the  overhanging  margins  of  the  inner  extremity  of  the 
canal  may  be  illuminated  by  rays  from  the  head  mirror. 

Botey  *  has  advised  the  use  of  small  mirrors,  which  are  to 
be  introduced  into  the  tympanic  cavity  for  the  purpose  of  in- 
specting the  parts  Iving  beyond  the  direct  line  of  vision  ;  but 
the  procedure  has  met  with  little  success.  Blake  f  suggested 
the  same  method  long  ago,  and  made  a  practical  application 
of  it  to  determine  the  attachment  of  a  growth  springing  from 
the  inner  extremitv  of  the  superior  wall  of  the  canal. 

In  the  preceding  pages  we  have  spoken  of  the  physical 
characteristics  revealed  by  ocular  inspection.  The  reader  is 
not  to  understand,  however,  that  the  eye  alone  is  to  be  used  ; 
a  delicate  probe  is  of  great  service  in  settling  a  doubtful 
appearance,  and  the  value  of  its  use  can  not  be  too  stronglv 
advocated.  Where  it  seems  unadvisable  to  use  a  metal  in- 
strument for  fear  of  injuring  the  delicate  structures,  a  very 
satisfactorv  substitute  is  found  in  the  use  of  what  may  be 
termed  a  cotton  probe,  constructed  as  follows:  A  small  bit  of 
cott(^n  is  wt>und  tightlv  about  the  extremitv  of  a  delicate  cot- 
ton holder  (Fig.  41 )  in  such  a  manner  that  the  cotton  shall 
project  for  about  a  quarter  of  an  inch  bevond  the  end  of  the 


Fi<;.  41. — Col  toil  holder. 

shaft,  it  being  wound  so  tightlv  as  to  offer  considerable  resist- 
ance upon  pressure,  and  constituting  really  a  prolongation  of 
the  probe.  This  cotton  tip  can  be  bent  at  any  desired  angle, 
and  is  firm  enough  to  retain  its  shape,  and  vet  not  so  firm  as  to 
injure  the  delicate  structures  encountered.  It  is  less  disagree- 
able to  the  patient  than  a  metallic  instrument,  while  it  is  of 
equal  service  to  the  examiner.  An  instrument  constructed  in 
this  manner  can  be  introduced  through  a  small  perforation  in 
the  membrana  tympani.  or  into  a  sinus  in  front  of  or  behind  the 
short  process,  and  be  carried  into  the  upper  part  of  the  cavity. 
Tactile  impressions  resulting  from  the  proper  manipulation  of 
the  instrument  afford  valuable  information. 

The  mobilitv  of  the  membrana  and  ossicles  should   be  de- 
termined as  the  next  step  of  the.  examination.     This  may  be 


*  Rev.  mens,  de  laryntjol..  vol.  .x,  p.  68i. 
f  Trans.  Am.  Old.  Society,  1872. 


THK    I'NEIMAIIC    SI'ECULl'M. 


lOI 


done  by  making  use  of  Siegle's  speculum  (Fig.  42).  It  con- 
sists of  a  hard -rubber  speculum,  the  wider  extremity  of 
which  is  screwed  tightly  into  one  end  of  a  short  cylinder  of 
the  same  material  as  the  speculum,  while  the  extremity  in- 
troduced into  the  canal  is  covered  with  a  small  bit  of  rubber 
tubing  to  effect  an  air-tight  closure  of  the  meatus.     The  op- 


I'lc.   42. — siegle's  pneumatic  speculum. 

positc  end  ol  the  cylinder  is  closed  by  a  caj)  wluch  makes  an 
angle  of  fortv-hve  degrees  with  the  axis  of  the  instrument. 
In  the  centre  of  this  cap  is  an  opening  covered  with  glass. 
Upon  one  side  of  this  cylindrical  chamber  is  an  opening  into 
which  a  short  tube  is  screwed.  The  free  extremity  of  the  tube 
is  connected  with  a  small  air  j)ump,  bellows,  or  atomizer  bulb 
by  a  short  piece  of  flexible-rubber  tubing. 

After  the  speculum  has  been  carefully  inserted  into  the 
external  auditory  meatus,  the  air  in  the  canal  can  be  exhausted 
bv  means  of  the  small  air  pump  or  rubber  bulb  with  which 
the  instrument  is  provided,  or  the  flexible  tube  may  be  held 
between  the  lips  and  the  air  withdrawn  in  this  manner.  The 
densitv  of  the  air  in  the  meatus  can  be  increased  if  desired  by 
reversing  the  direction  of  the  current.  The  glass  in  the  outer 
extremity  of  the  instrument  permits  the  examiner  to  watch  the 
different  motions  of  the  membrana  tvmj)ani  and  ossicles,  caused 
bv  the  alternate  condensation  and  rarefactifjn  of  the  air  in  the 
canal.  Were  the  glass  at  right  angles  to  the  axis  of  the 
speculum,  the  reflection  of  the  illuminating  rays  would  inter- 
fere with  the  view  of  the  deeper  parts,  but  this  is  avoided  if  it 
is  placed  at  an  acute  angle.  Under  normal  conditions  the  drum 
membrane  moves  outward  each  time  the  air  in  the  canal  is 
rarefied,  and  passes  in  the  opposite  direction  when  condensa- 
tion is  effected,  the  motion  being  most  evident  in  the  postero- 


I02  PHYSICAL    EXAMINATION. 

superior  quadrant.  The  malleus  at  the  same  time  rotates 
about  the  axis  band,  the  short  process  remaining  almost  im- 
movable, while  the  long  process  participates  in  the  outward 
excursion  of  the  membrane.  Areas  over  which  the  membrane 
is  adherent  to  the  inner  tvmpanic  wall  are  easily  recognized, 
since  they  are  not  affected  by  changes  in  the  air  pressure.  It 
is  also  important  to  note  closely  the  motion  of  the  malleus,  f(^r 
if  bound  down  at  its  tip  any  outward  excursion  is  impossible. 
Under  these  circumstances  it  either  remains  fixed,  the  mem- 
brane bulging  beyond  it  in  front  and  behind,  when  the  air  is 
exhausted,  or  it  may  move  slightly  outward  at  its  upper  part 
when  there  is  relaxation  of  the  structures  in  this  locality. 
Sometimes  intratvmpanic  adhesions  fix  the  malleus  in  such  a 
manner  that,  instead  of  rotating  about  the  axis  band,  it  rotates 
upon  its  long  axis.  This  is  frequently  observed  in  cases  where 
the  entire  ossicular  chain  and  the  membrana  are  drawn  inward 
as  a  whole  by  adhesions,  the  membrane,  therefore,  giving  no 
marked  evidence  of  malposition  except  that  it  appears  farther 
from  the  entrance  of  the  meatus  than  usual.  When  the  ex- 
cursions of  the  malleus  are  changed  in  character,  so  that  rota- 
tion takes  place  about  the  long  axis  of  the  ossicle,  we  are 
warranted  in  assuming  the  piescnce  of  extensive  intratvm- 
panic  adhesions,  together  with  some  relaxation  at  the  malleo- 
incudal  articulation. 

The  use  of  a  magnifving  lens  in  connection  with  the  pneu- 
matic speculum  is  seldom  of  advantage,  the  unaided  eye  dis- 
tinguishing variations  from  the  normal  quite  as  readily  as 
when  a  lens  is  used. 

Our  physical  examination  has  thus  far  been  confined  to 
those  parts  of  the  conducting  mechanism  which  can  be  inves- 
tigated by  sight  and  bv  touch.  We  now  have  to  call  to  our 
aid  the  sense  of  hearing  for  the  examination  of  parts  not  ac- 
cessible to  ocular  inspection.  These  parts  are  the  Eustachian 
tube  and  the  tvmpanic  cavitv. 

Inflation  of  the  Tympanum. — Since  the  tympanum  com- 
municates with  the  pharvngeal  vault  through  the  Eustachian 
tube,  a  sudden  condensation  of  air  in  the  vault  of  the  pharynx 
will  cause  a  corresponding  increase  in  air  pressure  in  the  mid- 
dle ear,  provided  the  Eustachian  tube  is  open.  The  tym- 
panum is  separated  from  the  external  meatus  onlv  by  the  thin 
membrana  tynipani,  and  the  examiner,  by  insertitig  a  flexible 
tube  into  the  meatus  of  the  patient  while  the  other  extremity 


INFLATION    OF    THK    TYMPANUM.  103 

is  inserted  into  his  own  auditory  canal,  is  able  to  recognize 
the  moment  when  the  air  enters  the  tympanum,  by  its  impact 
upon  this  delicate  partition.  The  sound  produced  in.dcr  nor- 
mal conditions  when  the  tvmpanum  is  suddenly  inflated  we 
mav  denominate,  for  convenience,  the  sound  of  inijiact.  it 
is  of  sharp,  metallic  character,  and  is  due  to  the  stretchini;; 
of  the  membrana  tvmpani  by  the  sudden  condensation  of 
the  air  within  the  middle  ear.  This  sound  seems  to  t)riginate 
in  the  ear  of  the  observer  on  account  of  the  extreme  thinness 
of  the  interposed  partition,  and  the  direct  conveyance  of  the 
sound  waves  to  his  ear.  lender  normal  conditions  but  a 
single  sharp  metallic  click  or  snap  is  heard.  This  mav  be 
followed  later  by  a  similar  sound  of  lower  pitch  and  of  less 
intensitv,  due  to  the  return  of  the  membrana  to  a  condition 
of  equilibriimi  in  \irtue  of  its  elasticity.  A  familiaritv  with 
these  signs  in  health  enables  the  observer  to  interpret  cor- 
rectly the  significance  of  any  modification  in  their  character 


In;.  43. — Auscultation  lubc. 

due  to  jiathological  conditions.  It  is  sometimes  stated  that 
auscultation  is  a  procedure  of  little  diagnostic  value,  but  I  can 
onlv  sav  that  the  otologist  w  ho  would  take  this  ground,  might 
be  compared  with  a  physician  who  would  consider  himself 
able  to  judge  of  intrathoracic  conditions  without  availing 
himself  of  auscultation  of  the  chest.  Auscultation  certainly 
affords  us  a  valuable  means  of  recognizing  certain  conditions 
within  the  tvmpanimi  and  Eustachian  tube,  if  practiced  suffi- 
ciently long  to  enable  one  to  interpret  the  significance  of  the 
various  sounds  heard. 

Methods  of  Inflation. — The  earliest  method  of  inflation  of 
the  middle  ear  is  that  which  bears  the  name  of  its  discoverer, 
Valsalva.  It  is  executed  by  the  patient  compressing  the  ala^ 
nasi  between  the  thumb  and  finger  of  one  hand,  thus  closing 
the  nostrils  ;  at  the  same  time  the  mouth  is  closed  and  the  at- 


I04 


PHYSICAL   EXAMINATION. 


tempt  is  made  to  force  air  through  the  nostrils — in  other  words^ 
to  blow  the  nose.  The  result  is  that  the  air  is  forced  into  the 
tympanum,  since  all  other  avenues  of  exit  are  closed.  The 
procedure  is  frequently  valuable  as  a  diagnostic  measure,  as 
the  surgeon  can  observe  the  effect  of  the  increased  intratym- 
panic  pressure  upon  the  drum  membrane,  bv  an  inspection  of 
the  part  while  the  patient  performs  the  inflation.  Depending 
as  it  does  upon  the  patient  himself  for  its  efficiency,  this  pro- 
cess possesses  but  little  therapeutic  value. 

The  most  universally  employed  method  of  inflating    the 
middle  ear  is  that  first  brought  into  prominence  by  Politzer,* 

and  bearing  his  name.  To 
force  air  through  the  Eusta- 
chian tube  by  this  procedure,^ 
the  surgeon  makes  use  of  a 
balloon-shaped  rubber  bulb,  to 
which  a  tube  of  the  same  ma- 
terial is  attached;  the  sudden 
c(jmpression  of  the  bulb  by  the 
hand,  expels  the  air  through 
the  free  end  of  the  tube  with 
considerable  force.  This  ex- 
tremitv  of  the  tube  is  provid- 
ed with  a  hard-rubber  lip,  so 
shaped  that  it  mav  be  inserted 
into  the  nostril  of  the  patient, 
or  in  some  instances  it  is  coni- 
cal in  form  so  as  to  occlude 
the  nostril.  In  inflating  with 
this  instrument,  the  nose  piece  is  held  in  position  by  the  fin- 
gers of  the  surgeon's  left  hand,  the  other  nostril  being  oc- 
cluded at  the  same  time  by  compressing  the  alie  of  both  sides  ; 
the  patient  is  then  directed  to  take  a  small  quantity  of  water 
into  the  mouth,  and  to  swallow  it  at  a  given  signal.  Coinci- 
dent with  the  act  of  deglutition  the  physician  compresses  the 
bulb,  which  he  holds  in  the  right  hand,  by  quickly  and  firmly 
closing  the  fingers  upon  it,  thus  driving  the  air  within  it  into 
the  pharyngeal  vault,  and  from  thence  into  the  tympanic  cavi- 
ties through  the  Eustachian  tubes.  The  action  of  swallowing 
shuts  off  the  pharyngeal  vault  completely  from  the  oro-phar- 


1- IG.  44. — rolitzer's  air-bag. 


*  Wien.  med.  Woch.,  1863,  No.  6. 


POLirZKRIZA  riON.  105 

vnx,  bv  the  elevation  of  the  soft  palate,  the  muscular  action 
effecting  this,  at  the  same  time  serving  to  render  the  tube 
more  ])ermeable,  in  the  manner  alreadv  described  in  consider- 
ing the  function  of  the  tubal  muscles.  Various  modifications 
of  this  procedure  have  been  devised,  the  success  depending 
largely  upon  the  intelligent  co-operation  of  the  patient.  The 
act  of  swallowing  must  be  coincident  with  the  compres- 
sion of  the  inflating  bulb  ;  otherwise,  the  naso-pharyngeal 
space  will  not  be  shut  off.  and  an  imperfect  operation  will  be 
the  result.  When  this  occurs,  the  operator  not  only  fails  to 
carry  out  the  measure  intended,  but  occasions  great  discom- 
fort to  the  j)atient,  and  occasionallv  to  himself,  for  the  sud- 
den entrance  of  the  air  into  the  oro-pharvnx  forces  the  water 
which  the  patient  is  attempting  to  swallow,  either  into  the 
larynx,  bringing  on  a  severe  seizure  of  coughing,  or  out  of  his 
mouth,  deluging  himself  and  operator  as  well. 

The  modifications  of  the  Politzer  method  have  been  de- 
signed to  obviate  such  accidents.  One  of  the  best  is  to  direct 
the  patient  to  close  his  lips  and  then  pufT  out  the  cheeks,  as 
though  trying  to  whistle  with  the  mouth  closed.  Another 
fairlv  successful  method  is  to  repeat  rapidly  the  letter  K,  or 
anv  syllable  containing  the  K  sound.  Either  of  these  proced- 
ures, causing  an  elevation  of  the  soft  palate,  efTects  a  fairly 
perfect  closure  of  the  pharvngeal  vault.  These  modifications 
are  of  particular  convenience  in  children,  and  render  the  ojjcr- 
ation  much  less  uncomfortable.  In  infants  the  act  of  crying 
produces  sufficient  closure  of  the  naso-pharygneal  space  to 
allow  of  a  successful  inflation  of  the  middle  ear,  if  the  air  bag 
is  forciblv  compressed  while  the  child  is  crying. 

There  can  be  no  question  of  the  value  of  Politzer's  method 
both  as  a  diagnostic  and  therapeutic  [)rocedure,  but  its  use 
should,  I  think,  be  restricted  to  certain  cases,  and  it  should 
not  be  adopted  to  the  exclusion  of  catheterization  of  the  tube. 

A  few  words  will  not  be  out  of  place  here  regarding  the 
selection  of  a  proper  inflating  bulb,  or  Politzer  bag,  and  of  a 
proper  tip  for  the  instrument.  The  error  usually  made  is  to 
choose  an  unnecessarily  large  bag.  A  large  instrument  is 
cumbersome  and  at  the  same  time  less  efficient,  since  it  can 
not  be  so  grasped  that  the  hand  is  able  to  compress  it  quickly. 
The  lumen  of  the  delivery  tube  is  frequently  so  small  in  pro- 
portion to  the  size  of  the  bag,  that  when  a  sudden  effort  at 
compression   is   made,  verv  little  air  is  forced  out,  the  ten- 


Io6  PHYSICAL    EXAMINATION. 

sion  in  the  bulb  almost  immediatclv  reaching  such  a  degree 
that  further  compression  is  impossible.  The  use  of  a  small 
bulb,  of  not  more  than  four  ounces'  capacity,  is  attended  with 
more  satisfactory  results;  the  instrument  can  be  easily  held 
in  the  palm  of  the  hand,  so  that  the  fingers  encircle  it,  and 
can  be  almost  completely  emptied  when  the  hand  is  quickly 
closed  upon  it.  The  actual  air  pressure  obtainable  with  a 
bulb  of  moderate  size  is  greater  than  with  one  of  large  di- 
mensions. It  is  immaterial  whether  the  air  bag  is  provided 
with  a  valve  which  allows  the  entrance  of  air,  but  closes  when 
the  bulb  is  compressed,  or  whether  it  has  but  a  single  open- 
ing, in  which  case  the  free  end  must  be  removed  from  the 
nostril  after  each  act  of  inflation.  When  this  last  form  of  bag 
is  employed  it  must  be  removed  from  the  nostril  before  the 
pressure  upon  the  bag  is  relaxed;  otherwise,  the  mucus  from 
the  nasal  cavitv  will  be  sucked  up  into  the  tube.  To  prevent 
this  accident  it  is  als(^  important  that  the  tip  be  wiped  imme- 
diately after  removal,  either  with  cotton  or  with  a  towel,  and 
before  allowing  the  bag  to  refill.  It  is  more  convenient  cer- 
tainly to  use  a  bag  provided  with  a  valve,  although  even  here, 
if  the  nose  piece  is  allowed  to  remain  in  position,  a  certain 
amount  of  mucus  may  be  aspirated  from  the  nasal  cavitv. 
The  objection  to  the  valve  lies  in  the  fact  that  it  is  liable  to 
get  out  of  order.  This  difTicultv  may  be  obviated  by  cutting 
a  hole  in  the  side  of  the  ordinary  bag,  and  covering  the  open- 
ing with  the  hand  during  the  act  of  compression ;  as  the  fin- 
gers are  relaxed  it  is  uncovered,  thus  allowing  the  balloon  to 
fill  readily.  This  is  certainly  more  simple  than  any  automatic 
valve,  and  demands  onlv  a  little  attention  on  the  part  of  the 
operator  to  see  that  perfect  closure  of  the  opening  is  effected 
at  each  act  of  inflation.  Pcrs(MialIv,  I  often  use  a  vcr}-  small 
bulb  of  a  capacity  of  about  two  ounces,  such  as  is  supplied 
with  the  ordinarv  hand-ball  nasal  atonii;ccr.  The  valves  in 
these  instruments  are  fairlv  well  made,  and  do  not  get  out  of 
order  rcadilv.  The  one  which  I  prefer  has  two  valves,  one 
allowing  the  air  to  enter  at  the  distal  end  o{  the  bulb,  while 
at  the  same  time  a  valve  at  the  opposite  extremitv  closes  the 
channel  between  the  bulb  and  the  nasal  cavitv  of  the  patient, 
preventing  the  entrance  of  mucus.  This  small  bulb  is  also 
particularly  adapted  for  use  with  the  catheter,  it  being  only 
necessary  to  change  the  tip. 

Regarding  the  particular  form  of  tip  suitable  for  insertion 


CATHETERIZATION.  I07 

into  tlic  nostril,  inrliviclual  j)rcfcrcnce  will  probably  be  the 
best  guide.  Manv  advocate  the  use  of  a  small,  curvctl  hard- 
rubber  ti{).  This  tube  is  inserted  into  the  inferior  meatus, 
where  it  is  held  between  the  fingers  and  thumb  of  the  left  hand, 
which  at  the  same  time  compress  the  ala?  nasi  so  tightlv  as  to 
allow  no  air  to  escape.  I  have  never  been  able  to  use  this  in- 
strument to  my  own  satisfaction,  although  there  is  no  question 
that  it  is  perfectly  efficient  in  other  hands.  The  objection  to 
its  use  is  that  the  introduction  of  the  tube  into  the  nostril  mav 
be  painful,  if  the  septum  is  considerably  deflected,  and  even 
when  the  greatest  care  is  used,  slight  hjemorrhage  may  follow 
the  {procedure.  If  this  form  of  tip  is  chosen,  care  should  be 
taken  that  its  calibre  is  am{)le,  permitting  a  large  volume  of 
air  to  pass  through  it.  As  the  instrument  is  usually  sold  in 
the  shojxs,  the  bore  is  very  small  in  comparison  with  the  ex- 
ternal diameter  of  the  tube.  It  is  also  wise  to  cover  the  end 
(jf  the  tube  to  be  introduced  into  the  inferior  meatus  with 
a  piece  of  thin  rubber  tubing,  as  an  abrasion  of  the  nasal  mu- 
cous membrane  is  less  liable  to  be  caused  if  this  is  done.. 

For  my  own  use  I  prefer  a  conical  tip,  which  occludes 
the  anterior  nasal  opening  perfectly  by  the  coaptation  of  its 
surface  with  the  soft  walls  of  the  opening  into  which  it  is  in- 
serted. This  conical  tip  may  be  constructed  either  of  glass, 
hard  rubl)cr,  or  aluminium,  and  care  should  be  taken  that  the 
opening  through  it  is  of  sufficient  size  to  allow  a  free  i)assagc 
of  the  air  when  sudden  condensation  is  effected.  In  children 
this  conical  tip  is  unquestionably  more  elTectual  and  more 
easily  manipulated  than  the  oiu'  pii'viou'-lv  mentioned. 

Catheterization  of  the  Eustachian  Tube. — By  this  manipu- 
lation the  surgeon  directs  a  current  of  air  into  the  tympanum 
of  one  side  t)r  the  other,  by  means  of  a  canula.  which  is  passed 
through  the  nasal  passages  into  the  vault  of  the  pharynx  and 
inserted  directh'  into  the  Eustachian  orifice. 

Before  giving  a  detailed  description  of  the  method  of  intro- 
ducing the  instrument,  a  lew  words  mav  be  said  concerning 
the  catheter  itself  (Fig. 

45).    It  consists  of  a  tube  ■  — t  — — ^|iwi^ 

of    either   hard    rubber,     9  ©  O    ©    © 

pure    or    coin    silver,    or  ^w..  ^s.-The  Eustachian  catheter. 

fjf  German  silver,  about 

eight  inches  long,  bent  in  the  arc  of  a  circle  at  one  extrcmit}', 

while  at  the  other  it  is  expanded  into  an  elongated  funnel, 


I08  PHYSICAL    EXAMINATION. 

which  constitutes  about  an  inch  of  its  length.  The  canula? 
vary  in  external  diameter  from  No.  3  to  No.  6  of  the  French 
scale.  The  expanded  end  of  the  catheter  is  provided  with  a 
guide  ring,  fastened  to  that  wall  of  the  tube  corresponding  to 
the  concavity  of  the  arc  described  by  the  pharyngeal  extrem- 
ity, for  the  purpose  of  informing  the  observer  of  the  position 
of  the  beak  of  the  instrument  when  in  the  nasal  cavity.  De- 
cided preference  should  be  given  to  the  pure  silver  instru- 
ments, since  the  curve  can  be  easily  changed  to  meet  the 
necessity  of  anv  individual  case.  German  silver  possesses  too 
little  flexibility  to  permit  of  the  instruments  being  easily  bent, 
while  the  hard-rubber  instruments,  although  they  can  be  molded 
into  anv  form,  after  they  have  been  heated,  usually  possess  so 
small  a  lumen  in  comparison  with  the  external  diameter  of  the 
tube,  as  to  render  them  unfit  for  use.  Even  in  the  pure  silver 
instruments  this  objection  occasionallv  exists,  the  walls  being 
unnecessarily  thick,  and  attention  should  be  directed  to  this 
point  in  selecting  the  catheter.  Care  should  also  be  taken  that 
the  margin  of  the  lumen  of  the  pharvngcal  extremitv  is  smooth, 
so  as  not  to  abrade  the  mucous  membrane  with  which  it  comes 
in  contact.  Hartmann  *  advises  that  the  tip  shall  be  slightly 
bulb-shaped  for  this  reason.  This  is  not  necessary  if  care  is 
taken  that  the  margins  of  the  opening  are  slightly  inverted, 
making  the  periphery  perfectly  smooth.  As  to  the  proper 
size  of  catheter,  it  is  ordinarily  stated  that  the  largest  instru- 
ment which  can  be  introduced  through  the  nasal  passages 
should  be  employed,  and  in  some  instances  an  instrument  of 
large  calibre  is  of  service.  It  should  be  remembered  that  the 
width  of  the  isthmus  of  the  tube  is  never  greater  than  one 
tenth  of  an  inch,  and  usually  its  diameter  is  less  than  this ; 
therefore  there  can  be  no  advantage  in  using  a  catheter 
whose  calibre  is  many  times  greater  than  this.  If  the  tube  is 
obstructed,  a  small  instrument  is  even  more  efficient,  since  the 
column  of  air  will  exert  a  greater  pressure  than  when  a  large 
instrument  is  used.  Any  advantage  gained  bv  an  instrument 
of  large  size  is,  I  think,  more  than  counterbalanced  by  the  in- 
creased delicacy  of  manipulation  which  the  smaller  allows, 
enabling  the  operator  to  locate  it  more  exactlv.  Regarding 
the  proper  curve  of  the  instruments,  this  must  of  necessity 
vary  in  different  cases,  according  to  the  width  of  the  pharyn- 


*  Krank.  des  Ohres,  Berlin,  1889^  p.  44. 


CA  rilK  IKRIZATION. 


1 09 


g-cal  vault,  the  prominence  of  the  tubal  oritices,  and  the  irregu- 
larities  met  with  in  the  nasal  chambers. 

Buck*  advises  that  the  curve  of  the  catheter  be  long  and 
gradual,  and  finds  this  form  adapted  to  a  greater  nimiber  of 
cases  than  one  in  which  the  radius  of  the  arc  is  shorter.  This 
shape  is  especially  valuable  where  the  inferior  meatus  is  ob- 
structed by  a  ridge  located  rather  low  down  on  the  septum. 
Many  times  a  sharper  curve,  such  as  advocated  bv  Urbant- 
schitsch,t  will  be  found  tt)  give  a  more  perfect  inflation. 
Herein  lies  the  advantage  of  the  pure-silver  instrument,  since 
it  can  be  molded  easily  into  any  desired  form,  according  to 
the  demands  of  each  case.  It  is  of  some  importance  that  the 
catheter  shall  not  be  so  long  that  when  in  jiosition  it  projects 
more  than  an  inch  and  a  cpiarter  bcvond  the  nasal  opening. 
It  is  more  difficult  to  maintain  the  instrument  in  a  fixed  posi- 
tion if  it  projects  farther  than  this,  since  anv  slight  motion 
serves  to  displace  it  from  the  tubal  orifice.  When  the  project- 
ing portion  is  short  verv  little  leverage  can  be  obtained,  and 
there  is  less  possibilitv  of  inflicting  injury  upon  the  delicate 
structures  encountered,  in  the  event  of  rough  manipulation. 

The  particular  device  to  be  used  for  effecting  inflation 
has  been  discussed  thoroujrhlv,  each  form  havinjr  its  advo- 
catcs.  The  ordinary  Politzer  bag  is  most  commonly  em- 
ployed, the  delivery  tube  terminating  in  a  conical  tip  which 
fits  into  the  outer  end  of  the  catheter  exactly  ;  or,  in  some 
instances,  the  tip  is  larger  than  the  mouth  of  the  catheter,  the 
bag  being  so  held  at  the  moment  of  compression  that  the  tube 
is  applied  as  closely  as  possible  to  the  mouth  (jf  the  cathe- 
ter, but  not  fitting  into  it  tightly,  thus  preventing  undue  pres- 
sure at  the  moment  of  condensation  of  the  air.  When  a  valve- 
less  air  bag  is  used  in  this  manner  it  must  be  removed  after 
each  act  of  compression  to  allow  it  to  refill,  and  the  repeated 
adjustment  to  the  lumen  of  the  catheter  can  not  but  disturb 
the  position  of  the  instrument,  and  be  a  source  of  discomfcjrt  to 
the  patient.  It  is  much  simj)ler  to  make  use  of  the  ordinary 
atomizer  bulb,  provided  with  a  valve  at  either  extremity  and 
connected  with  the  catheter  by  a  piece  of  rubber  tubing 
about  twelve  inches  long.  The  delivery  tube  is  joined  to  the 
catheter  through  the  interposition  of  a  conical  tube  ground 
to  fit  the  catheter  exactly  ;  this  allows  a  free  manipulation  of 

*  op.  cit.  \  Lehrb.  der  Ohren.,  Wien,  1890,  p.  8. 


no  PHYSICAL    EXAMINATION. 

the  bulb,  without  any  motion  being  imparted  to  the  catheter 
when  it  is  once  in  position.  When  this  apparatus  is  used  the 
hard-rubber  tube  is  fitted  into  the  catheter  before  the  instru- 
ment is  introduced  into  the  nose,  the  small  size  of  bulb  ren- 
dering it  possible  to  grasp  this  in  the  palm  of  the  hand,  while 
the  fingers  of  the  same  hand  hold  the  catheter  and  manipulate 
it  during  its  passage  through  the  nasal  cavity  (Figs.  46  and 
47).  This  allows  of  great  freedom  of  manipulation,  on  account 
of  the  length  of  the  tube  which  joins  the  catheter  to  the  bulb. 
After  the  catheter  is  once  in  place  the  fingers  of  the  left  hand 
fix  it,  while  with  the  right  hand  the  surgeon  comj^rcsses  the 
bulb  as  many  times  as  may  be  necessary.  Xo  motion  is  com- 
municated to  the  instrument  as  the  bulb  is  emptied,  and  no 
discomfort  attends  the  operation.  Certainly  from  a  humane 
point  of  yiew  this  method  is  to  be  preferred  ;  and  it  may  also 
be  said  that  since  the  mechanical  irritation  is  reduced  to  a 
minimum  the  therapeutic  value  is  also  greater. 

Lucae*  advises  the  interposition  of  an  clastic  bulb  be- 
tween the  inflating  bag  and  the  catheter  to  serve  as  a  re- 
ceiver, wliich  is  filled  by  the  compression  of  the  inflating  bag. 
The  elasticity  of  this  second  bulb  permits  of  the  introduction 
of  a  continuous  current  of  air  into  the  tympanum.  It  has 
never  in  my  experience  seemed  necessary  that  the  current  of 
air  should  be  continuous,  and  for  diagnostic  purposes  cer- 
tainly, it  would  be  of  less  value  than  an  intermittent  current. 

Many  Continental  otologists  advocate  the  use  of  a  higher 
air  pressure  than  can  be  obtained  by  any  of  the  above  instru- 
ments, and  emj)loy  some  form  of  air  pump  to  secure  the 
proper  amount  of  tension.  In  such  an  instrument  the  air  is 
forced  by  the  pump  into  a  large  receiver,  j)rovided  with  a 
gauge  for  registering  the  degree  of  condensation.  The 
Eustachian  catheter  is  connected  with  this  receiver  by  means 
of  a  flexible  tube,  and  the  air  is  allowed  to  escajie  through 
the  instrument  by  means  of  a  properly  adjusted  cut-off. 

When  the  Eustachian  tube  is  so  much  obstructed  that 
catheter  inflation  is  impossible  with  the  ordinary  air  bag,  some 
method  should  be  emj^loved  to  determine  the  exact  nature  of 
the  obstruction,  rather  than  to  attempt  to  perform  inflation 
with  very  high  air  pressure.  The  same  remark  will  apply  to 
the  use  of  anv  form  of  foot  bellows  for  a  similar  purpose.     Re- 


*  Archiv  fiir  Ohrenheilk.,  vol.  ii,  p.  308. 


CATHETERIZATION. 


II  I 


f^arding-  all  of  these  devices,  it  should  be  borne  in  mind  that, 
as  a  diagnostic  measure,  considerable  information  is  gained 
by  estimating  the  amount  of  force  necessary  to  empty  the 
bag  by  compressing  it  in  the  palm,  in  order  to  secure  a  free 
entrance  of  air  into  the  tympanum,  as  evidenced  by  auscul- 
tatory signs.  The  hand  and  ear  of  the  operator  then  act 
tt)gether,  allowing  him  to  interpret  the  relation  between  the 
intensity  of  any  particular  sound  heard,  and  the  force  neces- 
sary to  secure  the  degree  of  pressure  requisite  to  force  the 
air  into  the  tympanum  and  produce  the  sound. 

An  appropriate  catheter  and  inflating  apparatus  having 
been  selected,  the  next  step  is  the  technique  of  inserting  the 
instrument.  The  plan  which  seems  most  simple  will  be  first 
described,  after  which  other  methods  will  be  detailed. 

The  inflating  bulb  is  held  in  the  palm  of  the  right  hand, 
while  the  catheter,  having  been  propcrlv  connectctl  with  it,  is 
grasped  lightly  between  the  thumb  and  index  and  middle  fin- 
gers of  this  liand,  much  as 
a  pen  is  held.  The  shaft 
of     the     iii^t  t  iimi'nt     points 


Fig.  4f). — Introduction  of  the  Kus- 
tachian  catheter  (first  step). 


Fic;.  47.  — Introduction  of  the  Eus- 
tachian catlieter  (second  stej)). 


directly  ii])war(l.  while  the  curved  pharvngcal  portion  lies 
in  the  horizontal  {)lane,  the  orifice  of  the  catheter  looking 
forward.  The  patient  should  be  seated  in  a  chair  with  a 
high  back,  and  the  head  should  be  inclined  forward  slightly, 
while  at  the  same  time  he  should  be  directed  to  close  the  lips 
tightly  and  breathe  slowly  and  quietly  through  the  nostrils. 
The  operator,  either  standing  or  sitting  at  the  right  of  the  pa- 


1  12 


I^HVSICAL    EXAMINATION. 


tient,  tilts  the  tip  of  the  patient's  nose  upward  with  the  ball 
of  the  left  thumb,  the  index  and  middle  fingers  resting  upon 
the  nose  just  below  the  bridge.  From  this  moment  the  left 
hand  is  not  removed  from  the  patient's  nose  until  inflation  has 
been  accomplished  and  the  catheter  has  been  removed.  The 
tip  of  the  nose  being  elevated,  the  extremity  of  the  catheter  is 
introduced  into  the  nostril  {see  Fig.  46)  ;  as  soon  as  the  instru- 
ment has  passed  the  slight  ridge  at  the  nasal  orihce  the  opera- 
tor carries  the  hand  holding  the  instrument  upward  luitil  the 
catheter  assumes  a  horizontal  position.  In  this  position,  with 
the  tip  kept  constantly  upon  the  floor  of  the  nasal  cavitv,  the 
catheter  is  passed  directly  backward  through  the  inferior 
meatus  until  the  posterior  pharyngeal  wall  is  encountered 
(Fig,  47) ;  it  is  then  drawn  forward  about  three  eighths  or  one 
fourth  of  an  inch,  and.  remembering  that  the  guide  ring  on 
the  shaft  indicates  the  direction  in  which  the  pharyngeal  ex- 
tremity points,  the  instrument  is  rotated  upon  its  long  axis 
until  the  ring  points  almost  directly  outward  toward  the  side 
to  be  inflated.  The  hand  is  then  elevated  a  little  and  carried 
slightly  toward  the  opposite  ear,  causing  the  pharyngeal  ex- 
tremity of  the  instrument  to  descend,  and  at  the  same  time  to 
press  lightly  against  the  lateral  pharyngeal  wall.  By  drawing 
the  catheter  a  little  outward,  the  tip  will  be  felt  to  impinge 

upon  the  posterior  lip  of  the  tube  ;  it 
is  to  be  drawn  over  this,  the  tip  being 
turned  slightly  downward,  if  neces- 
sary, to  eflfcct  this  without  undue 
force.  As  soon  as  the  ojierator  knows 
by  the  sense  of  touch  that  the  promi- 
nent posterior  lip  has  been  passed,  the 
catheter  is  rotated  upon  its  long  axis 
until  the  guide  ring  points  upward 
and  outward  toward  the  ear.  while  at 
the  same  time  the  outer  extremity  of 
the  instrument  is  moved  toward  the 
opposite  side, thus  pushing  the  pharyn- 
geal extremity  well  into  the  mouth  of  the  tube.  When  care- 
fully placed,  the  sense  of  fixation  imparted  to  the  hand  is  un- 
mistakable. At  this  juncture  the  left  thumb  is  moved  so  as 
to  pass  beneath  the  catheter  and  support  it.  The  instrument 
is  thus  held  firmly  against  the  margin  of  the  nostril,  by  the 
thumb  below  and   the  first  three    fingers,    resting  upon  the 


->»^ 


Fir,.  48. — Introduction  of  the 
Eustachian  catheter  (tlic  in- 
strument fixed  in  the  mouth 
of  the  tube). 


AUSCULTATORY    SOUNDS.  1,3 

bridge  of  the  nose,  above  (Fig.  4S) ;  at  the  same  time  the  tip  of 
the  nose  is  pressed  upward  as  before.  The  right  hand  is  now- 
free  to  compress  the  bulb,  forcing  the  air  through  the  catheter 
into  the  middle  ear,  its  entrance  being  recognized  by  sounds 
heard  through  the  auscultation  tube. 

As  already  stated,  the  value  of  auscultation  for  diagnostic 
purposes  can  not  be  overestimated,  and  the  catheter  is  much 
superior  to  other  methods  of  inflation  when  the  operation  is 
performed  as  a  diagnostic  measure  only.  The  amount  of 
manual  pressure  necessary  to  force  the  air  into  the  tympanum 
is  also  of  importance  in  determining  the  degree  of  obstruction 
present,  and  this  may  be  roughly  estimated  by  the  operator 
with  each  act  of  compressing  the  bulb.  The  various  sounds 
produced  afford  exact  information  as  to  the  physical  condi- 
tion of  the  mouth  of  the  tube,  of  the  tubal  canal,  and  of  the 
tympanum.  These  advantages  are  not  offered  by  the  Politzer 
method  of  inflation,  since  the  efticiencv  of  the  procedure  de- 
])ends  entirely  ujxjn  the  ability  of  the  patient  to  close  the 
naso-pharyngeal  si)ace  completely  at  the  jtrojier  moment,  in 
catheterization  the  operator  has  the  entire  control  of  the  ])ro- 
cedure,  and  from  knowletige  derived  by  the  sense  of  touch  as 
to  the  exact  location  of  the  catheter,  and  by  an  estimate  of 
the  force  emjjloyed  during  tlie  act  of  inflation,  lie  is  able  to 
derive  valuable  information  from  the  various  auscultatory 
sounds  elicited  (.luring  the  ex[»eriment. 

Auscultatory  Sounds. — We  may  consider  that  the  sounds 
heard  through  the  auscultation  tube  are  produced  either  at 
the  piiarvngeal  orifice  of  the  tube,  or  within  the  lumen  of  the 
canal,  or  within  the  tympanum.  Frequently  the  ear  analyzes 
the  impressi(jn  made  upon  it  during  such  an  examination,  re- 
solving the  combination  of  sounds  heard,  into  the  several  sim- 
ple soimds  produced  at  each  of  these  locations. 

The  determination  of  the  point  at  which  a  given  sound  is 
generated  consists  in  measuring  its  intensity  or  its  proximity 
to  the  ear  of  the  examiner.  Since  the  tympanum  of  the  pa- 
tient is  separated  from  the  lumen  of  the  diagnosis  tube  simply 
by  the  drum  membrane,  any  sound  produced  by  the  air 
entering  the  tympanum  will  appear  to  originate  in  the  ear  of 
the  examiner.  We  also  remember  that,  on  entering  the  tym- 
panum, the  current  passes  from  a  narrow  canal  into  a  cavity 
of  comparatively  large  size,  and  we  should  expect  that  its 
character  would  be  modified   by  this  change  in  the  physical 


U4  PHYSICAL    EXAMINATION. 

conditions,  so  that  the  pitch  would  be  lowered  and  the  cjual- 
ity  softened. 

On  the  other  hand,  sounds  originating^  in  the  Eustachian 
canal  would  be  of  higher  pitch,  but  would  impress  the  listener 
as  though  they  came  from  a  greater  distance  from  his  ear 
than  the  tympanic  sounds.  Auscultation  sounds  originating 
in  the  naso-pharynx  or  at  the  pharyngeal  orifice  of  the  tube 
will  seem  still  more  distant,  being  heard  quite  as  well  with 
the  open  ear  as  through  the  auscultation  tube. 

T/w  Normal  Tympanic  Bruit. —  With  the  parts  in  a  normal 
condition  the  surgeon  hears  with  each  compression  of  the 
bulb  of  the  inflating  apparatus  a  soft,  dry,  blowing  sound, 
together  with  a  slight  but  distinct  percussion  sound  due  to 
the  impact  of  the  current  of  air  upon  the  drum  membrane. 
This  last  is  compared  bv  Deleau  *  to  drops  of  rain  as  they 
fall  upon  foliage  in  the  forest  during  a  shower.  The  "  blow- 
ing sound  "  is  produced  bv  the  passage  of  the  aerial  current 
through  the  catheter  and  Eustachian  tube  into  the  cavitv 
of  the  tvmj)anum  ;  the  "impact  sound,"  by  the  obstruction 
offered  bv  the  membrana  tvmj)ani  to  the  farther  progress  of 
the  air.  With  the  membrane  in  a  prt)per  position  and  under 
ni)rmal  tension,  this  last  sound  is  but  slightlv  marked,  and 
may  be  so  indistinct  as  to  be  entirelv  overlooked.  It  is 
possible,  however,  with  care,  to  make  out  the  tvmjianic.  tu- 
bal, and  pharvngeal  ci)niponents  of  the  auscultation  sound  in 
almost  every  instance.  We  have  next  to  examine  the  vari- 
ations which  the  normal  auscultation  sound  undergoes  when 
the  various  parts  are  not  in  a  condition  of  health.  We  will 
consider  these  according  to  the  special  region  in  which  they 
arise. 

I.  Tympanic  Sounds. — (^)  An  exaggeration  of  the  "impact 
sound  "  indicates  a  considerable  displacement  outward  of  the 
membrane  under  the  influence  of  the  increased  tympanic  pres- 
sure. Hence  the  membrane  must  have  been  retracted,  oc- 
cupving  an  abnormal  position — a  fact  already  determined  bv 
previous  speculum  examination  :  or,  if  occupying  a  normal 
position,  it  must  have  been  so  relaxed  as  to  admit  of  consid- 
erable outward  displacement  by  the  aerial  condensation.  If 
this  last  condition  exists  a  secondarv  sound  will  be  heard,  as 
the  hand  holding  the  bulb  relaxes,  thus  allowing  the  pressure 

*  Acad,  de  Sci.,  Dec.  7,  1829. 


TYMPANIC    SOUNDS.  II5 

in  the  niiddle  ear  to  diminish,  bv  the  escape  of  the  air  Iruin 
the  tvmpanuin  throuj^h  the  tube  into  the  pliarvny;eal  vault. 
The  amount  of  air  forced  backward  in  this  way,  and  conse- 
quently the  intensity  of  this  secondary  sound,  will  depend 
upon  the  resiliency  of  the  membrana  tympani  and  the  exact- 
ness with  which  the  catheter  fits  the  pharyns^eal  orihcc.  This 
secondary  sound  is  sharp  and  similar  to  tne  original  "  imjjact 
sound,"  but  less  intense. 

Sounds  haying  their  origin  within  the  tympanum  are 
heard  so  distinctly  that  those  not  accustomed  to  the  use  of 
the  auscultation  tube  will  frequently  describe  them  as  origi- 
nating within  their  own  ear. 

{/>)  If  now  the  tympanic  cayily  is  hlled  with  fluid  the  nor- 
mal "blowing"  and  "  impact "  sounds  undergo  a  change,  so 
that  a  rough  bruit  is  observed  in  place  of  the  *'  blowing 
sound,"  accomjjanied  and  followed  by  a  series  of  sharp  crack- 
ling rales  following  each  other  at  irregular  intervals,  and 
persisting  for  a  short  period  as  the  inflating  bulb  is  allowed 
to  retill.  This  rattling  apjjcars  to  be  in  the  ear  of  the  exam- 
iner, and  conveys  the  impression  of  a  current  of  air  being 
driven  through  a  collection  of  fluid.  The  quality  of  these 
rfdes  gives  some  hint  as  to  the  nature  of  the  fluid.  Crepita- 
tation  of  a  hne,  high-j)itched  character  is  heard  when  the  fluid 
is  watery,  but  the  rales  are  coarse,  low-pitched,  and  bubbling 
when  the  liquid  is  thick  and  viscid  and  adheres  to  the  walls 
of  the  cavity.  These  distinctions  are  ul  but  little  importance, 
as  the  exact  nature  of  the  fluid  is  of  no  moment.  It  must  also 
be  remembered  that  even  if  fluid  is  present,  it  may  lie  out 
of  the  course  of  the  current  of  air  which  enters  the  cav- 
ity, and  the  auscultation  sound  may  afford  no  evidence  of  its 
j'rcsence. 

(<•)  When  the  cavity  of  the  tympanum  is  cttmpletelv  hlled 
with  fluid  no  crepitation  is  heard,  as  the  air  fails  to  enter  the 
middle  car  at  all.  and  the  normal  "  blowing  sound  "  is  also 
wanting.  The  "  impact  sound,"  however,  is  heard  as  the 
current  of  air  enters  the  tube  and  impinges  upon  the  fluid 
contained  in  the  tympanum.  The  [percussion  sound.  hf)w- 
ever,  loses  its  sharp  character,  appearing  indi'^tinc  t.  distant, 
and  low-pitched. 

(<'/)  Any  solution  of  continuity  in  the  drum  membrane  is 
easily  discovered  upon  forcing  air  through  the  Eustachian 
tube,   provided   the   opening   through   the    membrana   is  not 


Il6  PHYSICAL    EXAMINATION. 

completely  shut  off  from  the  Eustachian  canal  by  adhesions. 
The  character  varies  with  the  size  of  the  opening,  being 
high-pitched  and  whistling  when  this  is  small,  and  of  a  blow- 
ing quality  when  the  area  destroyed  is  greater.  With  exten- 
sive destruction  of  the  membrana  the  air  is  felt  to  enter  the 
canal  of  the  examiner  and  to  impinge  upon  the  walls  of  the 
meatus.  The  pitch  of  the  note  heard  when  the  perforation 
is  of  moderate  size  will  depend  somewhat  upon  the  thickness 
of  its  edges.  Where  the  drum  membrane  is  greatly  swollen 
the  edges  do  not  vibrate  freelv  and  the  sound  is  rather  low- 
pitched.  Where  the  thickening  is  not  excessive,  and  espe- 
ciallv  if  the  membrane  is  fairly  tense,  a  high-pitched  note, 
known  as  the  "  perforation  whistle,"  is  heard. 

[e]  Certain  sounds  comparable  to  those  heard  when  two 
moist  surfaces  are  forcibly  separated  are  frequently  per- 
ceived upon  inflation,  and,  from  their  apparent  j)roximity  to 
the  ear  of  the  examiner,  evidentlv  originate  within  the  tym- 
panic cavity.  They  are  caused  by  the  separation  of  the 
membrana  from  the  inner  tympanic  wall,  by  the  act  of  infla- 
tion, and  are  met  with  in  cases  where  slight  hypersecretion 
has  taken  place,  allowing  the  two  opposing  surfaces  to  adhere. 
Occasionally  these  signs  indicate  the  rupture  of  newly  formed 
adhesions. 

(/)  When  the  middle  ear  is  the  seat  of  adhesive  inflam- 
mation, which  diminishes  the  size  of  the  cavity  by  drawing 
the  drum  membrane  inward,  or  when  this  structure  itself  is 
thickened  and  rigid  from  connective-tissue  hyperplasia  or 
from  calcareous  deposits,  or  where  the  tympanic  orifice  of 
the  tube  has  been  greatly  narrowed,  the  tympanic  factor  of 
the  bruit  is  practically  lost,  and  the  sound  seems  distant. 
This  is  observed  most  frequently  in  patients  of  advanced  years. 

2.  Tubal  Sounds. — In  passing  through  the  Eustachian  canal 
the  column  of  air  is  thrown  into  vibration,  producing  sounds 
which  vary  in  character  according  to  the  patency  of  the  pas- 
sage, the  condition  of  the  walls,  and  the  presence  or  absence 
of  moisture.  When  the  air  is  not  heard  to  enter  the  tym- 
panum, but  the  listener  is  conscious  of  a  distant  harsh  blowing 
sound  with  each  act  of  inflation,  the  catheter  being  correctly 
placed,  but  one  interpretation  can  be  made  of  the  sign — it 
must  indicate  stenosis  of  the  channel.  The  location  of  the  ob- 
struction is  determined  by  observing  the  relative  distance  at 
which  the  sound  appears  to  be  from  the  ear  of  the  examiner. 


TUBAL    SOUNDS. 


117 


It  approximates  more  nearly  to  the  pure  pharyngeal  sound 
according  as  the  barrier  is  located  nearer  this  orifice.  When 
the  bruit  is  fairly  constant  in  quality  and  intensity,  the  nar- 
rowing may  be  looked  upon  as  depending  upon  some  organic 
change  in  the  tubal  walls. 

On  the  other  hand,  if  its  character  changes  with  each  act 
of  compression  of  the  air  bag,  then  it  is  probable  that  the 
lumen  of  the  tube  is  closed  either  by  a  plug  of  secretion  or  by 
tumefaction  of  the  lining  membrane.  In  the  first  instance  the 
listener  hears  a  harsh,  moist,  rasping  sound,  the  pitch  of  which 
varies  each  time  the  air  is  forced  inward,  while  occasionally 
the  current  will  be  heard  to  rush  into  the  middle  ear.  This 
is  caused  by  the  momentary  displacement  of  a  mass  of  tena- 
cious mucus  which  occludes  the  channel,  permitting  the  air 
to  enter.  Prolonged  inflation  usually  dislodges  the  obstruc- 
tion and  allows  the  current  to  enter  the  tympanum  with  each 
compression  of  the  bulb. 

When  the  tube  is  narrowed  in  calibre  at  any  j)()int  by 
slight  swelling  or  by  a  hyj)erplastic  process,  the  blowing 
sound  is  of  higher  pitch,  according  to  the  degree  to  which 
the  channel  is  narrowed,  being  of  the  squeaking  or  whistling 
character  when  the  stenosis  is  nearly  complete.  When  due  to 
a  hyperplastic  process  the  sound  yaries  but  little  as  intlation 
continues,  while  it  it  depends  simply  upon  swelling  of  the 
walls  of  the  passage,  the  mucous  membrane  being  at  the  same 
time  moist,  the  bruit  changes  considerabh"  in  ciuality  as  the 
operation  is  continued,  moist,  crackling,  or  snaj)ping  sounds 
being  heard  from  time  to  time,  which  modify  the  high-{)itched, 
whistling  note.  The  sensation  of  proximity  to  the  observer  is 
wanting,  and  this  fact  indicates  the  tubal  origin. 

When  the  walls  of  the  tube  are  in  contact,  as  the  result  of 
oedema,  the  air  frequently  fails  to  enter  the  passage  when  an 
attempt  is  made  to  compress  the  bulb,  the  catheter,  if  properly 
located,  seeming  to  be  completely  occluded.  A  slight  move- 
ment of  the  instrument  and  repeated  efforts  at  inflation  pro- 
duces a  distant  clicking  noise,  followed  by  a  high-pitched 
whistle,  and  the  air  is  felt  to  rush  into  the  middle  ear  sudden- 
ly. This  phenomenon  repeats  itself  during  the  operation,  the 
air  entering  the  tympanum  only  after  the  bulb  has  been  com- 
pressed several  times,  and  then  but  in  small  quantit}*. 

It  is  scarcely  necessary  to  call  attention  to  the  signs  ob- 
served where  the  tube  is    abnormally  patent ;  one  need  only 


Il8  PHYSICAL    EXAMINATION. 

remember  that  the  intensity  of  the  tympanic  sound  must  be 
greater  if  the  tube  is  of  wide  calibre  than  if  it  is  narrowed. 
The  same  is  true  of  the  intensity  of  the  tubal  sound  itself.  At 
the  same  time  there  will  be  no  resistance  to  compression  of 
the  bulb. 

3.  PJiaryngcal  Sounds. — These  sounds  are  easily  recognized 
by  their  variable  character ;  they  are  heard  also  quite  as  well 
through  the  air  as  through  the  diagnosis  tube.  Even  when  a 
perfect  inflation  is  made  under  normal  conditions  a  soft,  indis- 
tinct blowing  sound,  depending  upon  the  escape  of  a  certain 
amount  of  air  into  the  pharyngeal  vault,  is  heard  with  the  open 
ear.  With  partial  or  complete  occlusion  of  the  Eustachian 
canal,  or  when  its  pharyngeal  orifice  is  filled  with  secretion, 
this  sound  becomes  louder,  and,  if  the  trumpet-shaped  orifice 
of  the  tube  contains  viscid  mucus,  is  of  a  hoarse,  rasping  qual- 
ity as  the  air  bubbles  through  it.  While  these  sounds  may  be 
heard  even  when  the  instrument  is  correctly  placed  if  the 
parts  are  swollen  and  inflamed,  still  they  most  frequently  in- 
dicate that  the  catheter  has  been  improperly  manipulated,  and 
that  the  tip  lies  in  Rosenmiiller's  fossa,  behind  the  tubal  ori- 
fice. Occasionally  the  catheter  is  pressed  so  forcibly  against 
the  lateral  wall  of  the  pharynx  as  to  com})lctely  occlude  the 
lumen,  and  no  air  can  be  forced  through  the  instrument  upon 
attempting  to  perform  inflation.  A  forcible  effort  at  infla- 
tion may  partially  overcome  the  resistance,  giving  rise  to  a 
harsh,  rasping  sound  as  the  current  passes  from  the  instrument 
and  overcomes  the  elasticity  of  the  mucous  membrane  which 
has  occluded  the  opening.  Sometimes,  instead  of  lying  ex- 
actly in  the  pharyngeal  orifice,  the  instrument  impinges  upon 
the  posterior  lip  of  the  tube.  The  pharyngeal  bruit  will  pre- 
dominate if  this  is  the  case,  and  will  be  of  a  particularly  dis- 
cordant, vibratory  character,  the  cartilaginous  plate  forming 
the  posterior  wall  of  the  tube  being  thrown  into  irregular  vi- 
brations each  time  the  bag  is  emptied. 

While  the  preceding  description  of  these  sounds  may  seem 
complicated,  their  recognition  is  simple  after  a  little  practice, 
and  it  is  easy  to  recognize  any  undue  prominence  of  the  tubal, 
tympanic,  or  pharyngeal  factors  of  the  bruit.  The  informa- 
tion gained  by  close  attention  to  this  method  of  examination 
will  amply  repay  one  for  the  labor  expended  in  jierfecting  him- 
self in  it. 

But  one  method  of  introducing  the  catheter  has  been  given 


METHODS    OK    CATHETERIZATION. 


119 


as  yet,  for  the  reason  that  it  has  seemed  better  to  take  this  one 
as  the  standard,  and  to  describe  the  variations  in  technique 
which  niav  be  resorted  to  when  this  hrst  method,  for  any  rea- 
son, is  not  successful.  It  is  advisable  for  the  beginner  to  ad- 
here closelv  to  one  method  of  catheterization  rather  than  to  re- 


FiG.  49. — Vertical  section  through  nasal  chambers  and  pharyngeal  vault  of  adult. 
The  lower  portion  of  the  septum,  opposite  the  inferior  turbinated  body  and  the 
inferior  meatus,  has  been  removed,  exposing  the  course  followed  by  the  cathe- 
ter.    The  Eustachian  orifice  is  well  marked.     (Author's  specimen.) 


sort  to  several  as  soon  as  difficulties  arise,  it  being  more  easy 
to  become  expert  in  the  manipulation  by  the  constant  use  of 
one  method. 

Loewenberg  *  modifies  the  technique  in  the  following  man- 
ner :  When  the  pharyngeal  extremity  of  the  catheter  is  felt  to 
impinge  upon  the  posterif^r  wall  of  the  naso-pharvnx  the  in- 


*  Arch,  fiir  Ohrenheilk.,  vol.  ii,  p.  12. 


I20 


PHYSICAL   EXAMINATION. 


strument  is  rotated  upon  its  long  axis  so  that  the  guide  ring 
shall  be  directed  toward  the  opposite  ear ;  the  catheter  is 
then  drawn  forward  until  its  concavity  is  felt  to  engage  the 
posterior  margin  of  the  nasal  septum  ;  it  is  then  rotated 
downward  through  an  angle  of  one  hundred  and  eighty 
degrees,  until  the  guide  points  toward  the  ear  to  be  inflated, 
while  at  the  same  time  the  catheter  is  carried  toward  this 
side. 

According  to  the  writer  quoted,  when  rotation  has  been 
completed,  the  beak  of  the  instrument  will  be  found  to  lie  in 


tj 

A 

Fig.  50. — A  section  made  in  the  same  manner  as  that  shown  in  I'ij^.  4(),  showing  the 
conformation  of  the  parts  in  a  child  of  live  years.  The  pharyngeal  vault  is  tilled 
with  adenoid  vegetations,  and  the  tubal  orifice  is  less  marked  and  lies  farther 
forward  than  in  the  adult.     (Author's  specimen.) 

the  mouth  of  the  Eustachian  channel.  The  jirolonged  manipu- 
lation is  rather  prone,  in  my  experience,  to  cause  a  contraction 
of  the  muscles  of  the  soft  palate,  and  therefore  constitutes  a 
source  of  discomfort  to  the  patient.  The  variations  in  the  ex- 
act position  of  the  tubal  orifice  and  in  the  transverse  diameter 
of  the  naso-pharynx,  detract  much  from  the  special  value  of 
this  method.  The  same  technique  had  previously  been  advo- 
cated by  Frank.*     Beyer  f  prefers  to  rotate  the  instrument 


*  Lehrb.  der  Ohreii.,  1S45,  p.  101. 

f  Annal.  des  nial.  de  I'oreille,  1S77,  vol.  iii,  p.  6g. 


METHODS    OF   CATHETERIZATION. 


121 


upon  its  long  axis,  as  S(3on  as  the  tip  passes  the  choana:,  as 
recognized  by  the  diniiiiished  sensation  of  resistance  to  the 
entrance  of  the  instrnment,  until  its  extreniitv  [loints  to  the 
afTected  side.  Its 
exact  insertion  into 
the  tubal  orifice  is 
effected  by  pressing- 
the  beak  outward 
toward  the  later- 
al pharyngeal  wall. 
This  method  is  oc- 
casionally of  service 
when  the  parts  are 
irritable,  and  the  o|)- 
erator  knows,  from 
previousexpericnce, 
the  exact  location  of 
tlie  tubal  opening. 

Triquet  *  follows 
almost  thesameplan, 
but  rotates  the  cath- 
eter before  it  leaves  the  inferior  meatus,  vo  that  it  inav  bt  arrest- 
ed bv  the  tubal  prominence  as  it  is  pushed  farther  backward. 

Wolff  +  and  Cirubcr:}:  advise  that  aftci-  the  instrument, 
with  the  pharvngeal  extreniitv  directed  downward,  has  been 
passed  through  the  inferior  meatus  until  the  pharyngeal  wall 
is  reached,  it  shall  be  drawn  forward  until  it  is  arrested  by 
the  soft  palate  ;  it  is  then  advanced  slightlv  toward  the  pos- 
terior pharvngeal  wall,  after  which  the  angular  jjortion  is 
rt)tate(l  toward  the  ear  to  be  inflated,  causing  the  extremity 
to  enter  the  tubal  mouth. 

Kramer**  suggests  that  use  be  made  of  the  reflex  contrac- 
tion of  the  soft  palate,  which  is  excited  bv  the  ])resence  of  the 
catheter,  to  cause  the  instrument  to  assume  its  correct  posi- 
tion in  the  tubal  mouth.  Having  carried  the  catheter  backward 
to  the  posterior  wall  of  the  naso-pharvnx,  it  is  drawn  forward 
over  the  prominent  posterior  lip  until  it  impinges  upon  the 
soft  palate.     This  manipulation  is  followed  by  a  contraction 


Fic.  51. — \  section  throuj^h  the  nasal  pass.igcs  and 
naso-pharynx  in  an  infant,  shnwing  ilic  turbinated 
bodies  and  tulial  orifice.  1  In-  lii)s  of  the  lul)e  are 
poorly  defined.  A  similar  condition  is  fie<iuently 
met  with  in  ad\aiiceil  life-,     f. Author's  v|)e(.inien.) 


*  Traite  pratique  des  mal.  de  I'oreille,  1857. 
\  Lencke's  Handb.  der  Ohrenheilk.,  vol.  iii,  p.  358. 
X  I.ehrb.  der  Ohrenheilk.,  Vienna,  1888,  p.  203. 
<*  Ohienkrankheit.,  1836,  p.  248. 


122  PHYSICAL    EXAMINATION. 

of  the  palatal  muscles,  which  forces  the  instrument  upward. 
At  this  instant  it  is  quickly  rotated  toward  the  affected  side, 
the  contraction  of  the  palate  crowding  it  into  the  tubal  orifice. 

It  will  be  seen  that  in  all  of  these  methods,  with  the  ex- 
ception of  Frank's,  the  technique  of  introduction  is  but 
slightly  modified  from  that  first  described,  and  that  the  facil- 
ity with  which  the  operation  can  be  performed  will  depend 
greatly  upon  the  ability  of  the  operator  to  recognize  the 
yarious  structures  which  the  pharyngeal  extremity  impinges 
upon,  after  the  instrument  has  entered  the  naso  pharynx. 

Obstacles  to  Catheterization, — Certain  difficulties  depend- 
ing upon  anatomical  characteristics  peculiar  to  any  giyen 
case  may  be  encountered  in  attempting  to  perform  catheter- 
ization. The  most  frequent  obstacle  is  a  considerable  de- 
formity of  the  septum  narium,  causing  a  partial  occlusion 
of  the  inferior  meatus.  Since  the  introduction  of  cocaine, 
catheterization  has  become  mucii  more  simple,  as  the  ex- 
sanofuination  of  the  turbinated  tissues  increases  the  dimen- 
sions  of  the  cayity  materially,  while  at  the  same  time,  on 
account  of  its  ana?sthetic  properties,  prolonged  manipula- 
tion is  possible.  Before  attempting  to  introduce  the  Eus- 
tachian catheter,  it  is  always  wise  to  make  a  careful  ante- 
rior rhinoscopic  examination,  to  determine  the  presence  and 
nature  of  any  obstruction.  If  a  considerable  obstructiye 
lesion  exists,  the  catheter  may  be  introduced  under  direct 
inspection,  the  parts  being  illuminated  by  reflected  light, 
and  the  eye  directing  the  yarious  moyements  of  the  instru- 
ment until  it  has  entered  the  naso-j  harynx.  A  ridge  upon 
the  septum,  which  extends  horizontally  toward  the  outer 
wall  of  the  cayity,  is  perhaps  the  most  perplexing  condition 
found.  The  curye  of  the  catheter  must  be  such  that  it  may 
traverse  the  inferior  meatus  beneath  the  obstructing  ridge  ; 
herein  lies  the  advantage  of  a  pure  silver  catheter,  since 
it  is  a  simple  matter  to  change  the  curve  of  the  instrument 
to  suit  the  particular  condition  encountered  in  any  case. 
It  is  not  always  possible  to  introduce  the  instrument  with 
the  curved  extremity  pointing  downward,  when  a  prominent 
ridge  or  excrescence  presents  anteriorly,  and  it  is  often  ad- 
visable in  such  cases  to  turn  the  tip  of  the  catheter  to  one  or 
the  other  side,  effecting  its  introduction  into  the  cavity  in  the 
oblique  diameter  rather  than  in  the  vertical.  Again,  when 
there  is  a  prominent  ridge  at  the  very  entrance  of  the  vesti- 


OBSTACLES    TO    CATHKTKKIZATION.  1 23 

bule,  and  the  passaj^e  beyond  is  obstructed  as  well,  it  niav  be 
necessary  to  enter  the  nasal  cavil v  with  the  catheter  so  held 
that  the  conca\itv  is  directed  upward,  the  conve\it\-  a{)plv- 
ing  itself  to  the  depression  just  within  the  vestibule.  In  such 
a  case,  as  soon  as  the  naso-pharvngeal  space  is  entered,  the 
instrument  should  be  rotated  imtil  it  has  assumed  the  proper 
position.  This  rotation  should  be  made  toward  the  unaf- 
fected side  to  avoid  touching  the  lateral  pharvngeal  wall. 

It  sometimes  happens  that  the  conformation  of  the  parts 
will  not  allow  the  instrument  to  enter  the  inferior  meatus, 
although  the  middle  meatus  may  be  capacious.  In  such  an 
event,  if  the  catheter  is  so  bent  as  to  increase  the  length  of 
the  angular  portion,  it  is  a  simple  matter  to  pass  it  through 
the  middle  meatus,  above  the  obstruction,  until  the  pharvn- 
geal  wall  is  encountered  ;  after  it  has  passed  into  the  naso- 
pharynx the  e.Ktremitv  of  the  instrument  held  in  the  fingers 
is  elevated — a  manij)ulation  which  will  allow  the  long,  angular 
part  to  engage  in  the  tubal  mouth  uj)on  rotation,  altht)ugh 
the  horizontal  portion  of  the  instrument  lies  at  a  higher  level 
than  the  entrance  of  the  tube.  Naturallv,  the  greatest  deli- 
cacv  must  be  exercised  in  conducting  this  procedure,  as  from 
the  increased  length  of  the  angular  portion  it  will  be  easy  to 
wound  the  delicate  tissues  of  the  naso-pharvnx  in  rotating 
the  instrument  upon  its  long  axis  at  the  moment  when  the 
extremitv  is  carried  into  the  mouth  of  the  tube. 

When  one  nasal  passage  is  blocked  so  that  the  intnxluction 
of  a  catheter  is  impossible.it  mav  be  carried  through  the  pas- 
sage of  the  opj)Osite  side,  as  advised  bv  Deleau.*  The  curved 
portion  of  the  catheter  must  be  considerably  longer  than 
usual,  and  if  the  vault  of  the  phai'vnx  is  unusuallv  wide  the 
procedure  is  not  satisfactorv.  as  a  rule.  The  technique  con- 
sists of  carrving  the  instrument  through  the  nasal  jjassage  of 
the  opposite  side,  the  free  extremitv  resting  upon  and  gliding 
along  the  floor  of  the  inferior  meatus.  When  the  posterior 
pharvngeal  wall  is  encountered  the  instrument  is  rotated  so 
that  the  pharyngeal  extremity  points  toward  the  ear  to  be  in- 
flated. The  catheter  is  made  to  enter  the  fossa  of  Rosenmiiller 
by  carrying  the  extremity  of  the  instrument  held  between  the 
fingers  awav  from  the  septum,  imtil  further  motion  is  pre- 
vented by  the  lateral  pharyngeal  wall.    The  instrument  is  now 

*  Rev.  med.,  1S27. 


124 


PHYSICAL    EXAMINATION. 


drawn  outward  for  about  one  fourth  of  an  inch,  or  until  the 
prominent  posterior  lip  of  the  tube  is  felt ;  it  is  made  to  glide 

over  this  by  drawing  it  outward, 
while  at  the  same  time  the  outer 
extremity  of  the  instrument  is  ele- 
vated so  as  to  allow  the  angular 
portion  to  pass  over  the  posterior 
lip  of  the  tube  close  to  its  lower 
margin  ;  the  outer  extremity  of  the 
instrument  is  then  carried  away 
from  the  side  to  be  inflated — a  ma- 
nipulation which  forces  the  pharvn- 
geal  end  into  tiie  mouth  of  the  Eus- 
tachian tube.  This  method  of  ca- 
theterization is  unsatisfactorv  to 
the  surgeon  and  painful  to  the  pa- 
tient, the  length  of  the  angular  por- 
tion of  the  catheter  making  delicate 
manipulation  an  impossibility,  while 
at  the  same  time  it  projects  so  far 
downward  that  when  the  instru- 
ment is  rotated,  considerable  irri- 
tation of  the  pharyngeal  mucous 
membrane  is  produced.  Noyes  has 
devised  a  catheter  (Fig.  52),  the 
pharyngeal  extremity  of  which  is 
bent  at  first  downward  and  then 
upward  and  outward,  which  en- 
ables catheterization  to  be  per- 
formed through  the  opposite  nostril 
s(^mewhat  more  easily  than  when 
the  ordinarv  Eustachian  catheter  is 
emploved.  If  the  operator  uses  the 
silver  catheters,  which,  on  account 
of  their  malleability,  can  be  made 
to  assume  anv  desired  curve,  it  is 
comparatively  simple  to  convert  an 
ordinarv  Eustachian  catheter  into 
one  possessing  a  double  curve  by 
bending  it  between  the  fingers.  By 
a  careful  inspection  of  the  nasal  passage  through  which  the 
instrument  is  to  be  introduced,  the  operator  will   be  able  in 


OBSTACLES    TO    CATHETERIZATION. 


125 


many  instances  so  to  mold  the  instrument  as  to  render  its 
introduction  comparatively  simple.  By  giving  it  the  double 
curve  already  described  we  overcome  the  necessity  of  the 
increased  length  of  the  angular  portion,  which  is  always  a 
source  of  discomfort  to  the  patient. 

One  other  method  of  catheterization  remains  to  be  de- 
scribed— viz.,  the  introduction  of  the  instrument  through  the 
mouth.  This  was  tirst  advised  bv  Kessel  *  in  cases  in  which 
the  nasal  passages  were  occluded.  Pomeroy  +  in  this  coun- 
try has  been  an  ardent  advocate  of  the  procedure,  and  fre- 
quently employs  it  in  preference  tt)  the  usual  method.  He 
has  devised  a  special  instrument  which  is  shown  in  Fig.  53. 


Fl<;.  53. — romeroy's  faucial  cilheter 


As  I  have  had  no  personal  experience  with  this  method,  I  can 
give  no  opinion  as  to  its  utilitv.  It  is  simplv  mentioned  here 
as  an  available  procedure,  which  mav  be  emjjloyed  at  the  dis- 
cretion of  the  surgeon. 

Deformities  of  the  nasal  passages,  however,  are  not  the 
only  obstacles  to  catheterization.  The  exact  location,  form, 
and  prominence  of  the  pharvngeal  extremity  of  the  Eustachian 
tube  varies  not  onlv  in  different  cases,  but  also  in  the  same 
individual  at  difTcrent  times,  according  to  the  degree  of  con- 
gestion of  the  surrounding  parts.  The  position  and  shape  of 
the  pharvngeal  orifices  mav  also  be  asvmmetrical  in  the  same 
individual.  It  frequently  happens  that  the  tubal  lips  are  so 
poorly  developed  that  their  recognition  by  the  sense  of  touch 
is  almost  impossible  ;  on  the  other  hand,  they  may  be  so  ab- 
normally developed   that  difficulty  is  experienced  either  in 


*  Archiv  fur  Ohrenheilkunde,  vol.  xi,  p.  218. 
f  Diseases  of  the  Ear,  New  York,  1883,  p.  28. 


126  PHYSICAL    EXAMINATION. 

drawing  the  instrument  forward  over  the  posterior  lip  or,  in 
some  cases,  even  in  passing  it  backward  sufficiently  to  permit 
rotation.  The  pharyngeal  vault  is  occasionally  so  wide  that 
upon  rotation  the  catheter  reaches  the  lateral  wall  with  ditifi- 
cultv.  In  such  an  event  the  straight  portion  of  the  cathe- 
ter must  be  crowded  so  far  toward  the  nasal  septum  as  to 
cause  considerable  discomfort  by  pressure  upon  the  intra- 
nasal structures,  or  the  angular  portion  must  be  so  long  as 
to  render  the  passage  of  the  instrimient  through  the  nasal 
chamber  difficult,  and  to  render  rotation  almost  impossible. 

Again,  the  mouth  of  the  tube  mav  be  located  high  up  in 
the  vault  of  the  pharynx,  and  its  shape  may  be  such  that  the 
catheter  must  be  rotated  through  an  angle  of  at  least  135°, 
or  even  more,  before  its  tip  rests  in  the  mouth  of  the  tube  so 
as  to  permit  of  a  fullv  successful  inflation. 

It  is  only  necessarv  to  bear  in  mind  these  various  obstacles 
in  order  successfully  to  overcome  them.  Delicate  manipula- 
tion will  enable  the  operator  to  recognize  the  posterior  lip  of 
the  tube  after  a  little  practice,  even  if  it  projects  only  slightly 
above  the  smooth  lateral  wall  of  the  pharvnx.  Where  the 
pharynx  is  abnormally  wide,  the  curved  portion  of  the  instru- 
ment must  be  increased  in  length,  and  if  rotation  can  not  be 
accomplished  in  the  ordinary  way,  the  outer  extremity  of  the 
catheter  should  be  elevated  as  much  as  possible  to  effect  a 
corresponding  depression  of  the  tip  of  the  instrument,  to 
enable  it  to  pass  below  the  tube,  after  which  rotation  can  be 
performed  easily.  The  timidity  of  the  patient  when  catheter- 
ization is  performed  for  the  first  time  is  another  difficulty  to 
be  mentioned.  This  is  especially  the  case  if  the-mucous  mem- 
brane of  the  nasopharynx  is  irritable,  in  which  event  the  mus- 
cles frequently  contract  the  moment  the  instrument  enters 
the  cavity,  and  hold  it  so  firmly  in  their  grasp  as  to  prevent 
its  rotation  into  the  mouth  of  the  tube.  This  spasm  of  the 
palatal  muscles  causes  the  instrument  to  be  so  firmly  grasped 
that  its  mere  presence  in  the  pharyngeal  vault  is  painful. 
The  slightest  motion  augments  this  pain  and  increases  the 
muscular  rigidity,  so  that  it  is  quite  as  impossible  for  the  oper- 
ator to  withdraw  the  catheter,  as  to  proceed  with  the  opera- 
tion. Occasionall)-  no  inconvenience  is  experienced  until  ro- 
tation is  attempted,  when  contact  with  the  lateral  wall  of  the 
pharynx  excites  the  act  of  deglutition,  and  the  sudden  mus- 
cular contraction  displaces  the  catheter  and  crowds  it  against 


OBSTACLES    TO    CATUKTKRIZATION.  12/ 

the  lateral  wall  of  the  pharyngeal  space  with  considerable 
force.  If  the  patient  is  directed,  at  the  outset,  to  keep  the 
mouth  closed  and  respire  res^ularly  and  quietly  through  the 
nostrils,  there  is  much  less  danger  of  such  reflex  muscular 
contraction.  If  as  the  instrument  enters  the  pharynx  the  pa- 
tient shows  an  inclination  to  cough  or  to  swallow,  it  is  well  to 
divert  his  attention  by  requesting  him  to  close  the  lips  and  to 
breathe  (juickly  and  deeply  through  the  nose.  Even  an  at- 
tempt to  do  this  will  cause  a  momentary  relaxation  of  the 
palatal  muscles,  and  during  the  interval  the  introduction  of 
the  instrument  can  usually  be  cfTcctcd.  If  reflex  contraction 
of  the  muscles  takes  |)lace  in  sj>ite  of  all  j)recautions,  the  in- 
strument should  be  held  perfectly  still  fluring  the  period  of 
muscular  s[)asm,  as  any  attemj^t  to  withdraw  or  advance  it 
adds  seriously  to  the  discomfort.  Relaxation  is  sure  to  take 
place  in  a  few  seconds,  and  then  the  instrument  can  be  carried 
to  the  proper  position  or  removed,  as  seems  desirable.  Re- 
flex cough  occurring  during  the  act  of  catheterization  should 
be  managed  in  the  same  maimer.  It  is  to  be  remembered  that 
when  the  instrument  is  once  in  position,  coughing,  swallow- 
ing, or  any  other  muscular  movement  does  not  interfere  with 
it  in  the  slightest,  and  when  ct^rrectly  placed  its  j)resence 
causes  no  discomfort. 

It  occasionally  hai)j)ens  that,  bv  mistake,  the  catheter  is 
passed  through  the  middle  meatus  instead  of  through  the  in- 
ferior channel.  This  need  never  occur  accidentally  if  the 
head  of  the  patient  is  maintained  in  a  slightly  flexed  position. 
The  almost  irresistible  impulse  on  the  part  of  the  patient  to  ex- 
tend the  neck  causes  the  instrument  to  enter  the  middle  me- 
atus, even  when  it  is  passed  horizontally  inward.  With  the 
head  bent  slightly  forward  this  can  not  occur.  It  must  be 
borne  in  mind,  in  conclusion,  after  discussing  the  {)rincipal 
difficulties  met  with,  and  suggesting  measures  to  avoid  and 
overcome  them,  that  the  utmost  gentleness  must  be  exercised 
throughout  the  entire  performance  of  the  operation.  The 
catheter  should  be  allowed  to  find  its  way  into  the  pharyngeal 
vault,  and  should  be  allowed  to  rotate  one  way  or  the  other, 
as  may  seem  necessary  to  avoid  obstacles.  It  is  only  neces- 
sary for  the  operator  to  pirevent  its  passage  into  the  middle 
meatus.  When  the  nasal  channel  is  extremely  irregular  com- 
plete rotation  about  the  long  axis  of  the  catheter  frequently 
occurs  during  its  course  from  the  anterior  to  the  posterior 


128  PHYSICAL    EXAMINATION. 

nasal  opening.  The  slightest  pressure  is  sufficient  to  advance 
it  when  properly  directed,  and  no  force  should  be  used.  Any 
haemorrhage  following  catheterization  is  a  reproach  to  the 
operator  in  every  instance.  It  is  true  that  an  occasional  abra- 
sion of  the  nasal  mucous  membrane  occurs  at  the  hands  of  the 
most  careful  manipulator,  but  one  should  always  feel  that 
there  is  no  excuse  for  the  accident.  It  is  a  procedure  in 
which  gentleness  and  care  should  be  combined  with  skill,  and 
he  who  can  not  exercise  these  is  incompetent  to  carrv  out  the 
operation. 

As  to  the  use  of  cocaine  for  the  production  of  local  anaes- 
thesia, it  mav  be  said  that  since  the  drug  has  come  into  com- 
mon use,  it  is  frcquentlv  employed  for  this  purpose  in  cathe- 
terization. It  ccrtainlv  diminishes  the  discomfort  attending 
the  passage  of  the  instrument  through  the  nose,  if  the  channel 
is  irregular  or  narrow,  and  at  the  same  time  by  shrinking  the 
turbinated  bodies  increases  the  width  of  the  nasal  passage. 
It  mav  be  stated,  however,  that  imder  normal  conditions  the 
inferior  meatus  is  not  sensitive  to  the  presence  of  the  instru- 
ment, and  observations  upon  quite  a  large  number  of  cases 
in  reference  to  this  point  have  convinced  me  that  quite  as 
much  discomfort  follows  catheterization  when  local  anaes- 
thesia is  employed,  as  when  no  cocaine  is  used.  In  many,  the 
disagreeable  sensation  as  of  a  foreign  body  in  the  pharynx, 
due  to  the  drug,  constitutes  a  much  greater  source  of  dis- 
comfort than  that  produced  by  the  introduction  of  the  instru- 
ment without  local  anaesthesia.  No  objections  can  be  raised 
to  the  use  of  cocaine,  however,  and  it  is  alwavs  wise  to  em- 
ploy it  in  cases  where  the  nasal  passages  are  so  tortuous  as 
to  necessitate  rather  prolonged  manipulation.  Moreover,  the 
knowledge  on  the  part  of  the  patient  that  the  drug  has  been 
used,  certainly  produces  a  i)n)found  mental  imjM-ession,  and 
relieves  any  anxietv  as  to  the  discomfort  to  be  endured.  The 
drug  is  best  a|)plied  in  a  ten-per-cent  solution,  a  small  ciuan. 
tity  being  hrst  sprayed  into  the  nostril  by  means  of  an  ordi- 
nary hand-ball  atomizer.  A  few  moments  suffice  to  secure 
contraction  of  the  turbinated  tissues,  during  which  time  it  is 
well  to  have  the  head  inclined  a  little  forward  to  prevent  the 
passage  of  the  solution  into  the  pharyngeal  vault.  Next,  a 
cotton  holder,  mounted  with  a  small  pledget  of  cotton  mois- 
tened with  the  same  solution,  is  to  be  passed  through  the  in- 
ferior meatus,  along  the  course  to  be  traversed  by  the  cathe- 


DANGERS    OF    CATHETERIZATION. 


129 


tcr,  the  manipulation  being  conducted  luider  illuinination 
from  the  head  mirror.  The  applicator  should  not  be  carried 
be}ond  the  choanal  if  the  unpleasant  sensation  of  fullness  in 
the  pharynx  which  the  drug  causes  is  to  be  avoided.  If 
there  is  reason  to  suspect  that  the  naso-pharvnx  will  be  ini- 
usually  irritable — a  condition  with  which  we  frequently  meet 
in  cases  of  acute  naso-pharyngitis — it  is  well  to  anaesthetize 
the  mouth  of  the  tube  as  well  as  the  nasal  passages.  This  is 
done  by  means  of  the  cotton-tipped  probe,  the  extremity  t)f 
which  is  bent  to  correspond  to  the  curve  of  the  catheter. 
Under  inspection,  this  instrument  is  to  be  passed  through  the 
nasal  passage  exactly  as  the  catheter  would  be  introduced, 
care  being  taken  that  the  patient's  mouth  is  closed,  and  quiet 
nasal  respiration  continued.  The  same  manipulation  em- 
ployed in  the  introduction  of  the  catheter  enables  the  cotton- 
tipj)ed  probe  to  be  inserted  into  the  orifice  of  the  Eustachian 
canal,  care  being  taken  that  the  jiledget  is  not  saturated  with 
the  solution,  as  otherwise  a  considerable  quantity  will  be 
spread  over  the  pharyngeal  mucosa.  When  the  orifice  of 
the  tube  is  reached,  the  applicator  is  allowed  to  remain  in 
this  position  for  a  few  seconds  to  ablate  comj)letelv  the  sensi- 
tiveness of  the  mucous  membrane;  catheterization  is  now 
easily  performed.  In  addition  to  securing  local  anasthesia 
by  the  introduction  of  the  cotton  pledget  in  the  manner  al- 
ready described,  the  o|)erator  accomplishes  another  purj)Osc, 
since  he  cleanses  the  orifice  of  the  tube  and  removes  any  in- 
spissated secretion  which  mav  be  present,  and  which  would 
be  an  obstruction  to  successful  intlation. 

The  Dangers  of  Catheterization. —  I'rom  the  fact  that 
three  deaths  have  followed  the  procedure  it  is  looked  uj)()n 
by  those  unacquainted  with  the  ojieration  with  a  certain  de- 
gree of  perturbation.  Inflation  in  these  fatal  cases  was  per- 
formed by  means  of  compressed  air,  the  degree  of  condensa- 
tion being  extreme.  This  method,  as  already  stated,  is  seldom 
used  at  present,  and  it  is  safe  to  say  that  no  damage  can  be 
done  with  any  form  of  hand  apparatus  devised  for  the  purpose 
of  inflating  the  middle  ear  through  a  catheter. 

Death  in  these  cases  was  probably  caused  by  suffocation 
from  submucous  emphysema,  due  to  the  air  having  been 
forced  beneath  the  mucous  membrane,  the  surface  of  which 
had  been  abraded  by  the  extremity  of  the  catheter.  The  oc- 
currence of  emphNsema  need  not  of  necessity  be  followed  by 
10 


•30 


PHYSICAL    EXAMINATION. 


serious  results,  although  the  symptoms  which  supervene  arc 
always  alarming  to  the  patient,  and  may  be  disturbing  to  the 
operator.  When  this  accident  occurs,  the  air  may  either  be 
absorbed  spontaneously,  or,  if  the  emphysematous  area  is  ex- 
tensive, the  condition  may  demand  relief  by  surgical  interfer- 
ence. Puncture  of  the  tissues  suffices  to  evacuate  the  air  and 
to  relieve  the  symptoms  at  once.  It  should  be  stated,  how- 
ever, that  if  even  ordinary  care  is  used  in  catheterization,  em- 
physema will  never  be  produced,  and  one  who  can  not  intro- 
duce the  Eustachian  catheter  without  abrading  the  mucous 
membrane  of  the  naso-pharynx  had  better  not  introduce  it  at 
all.  The  onh'  possible  excuse  for  the  accident  would  be  cathe- 
terization immediately  after  the  introduction  of  the  Eustachian 
bou£:ie  ;  therefore  it  should  be  the  invariable  rule  never  to  in- 
fiate  the  middle  car  at  once  after  the  passage  of  such  an  in- 
strument. 

Occasional! v,  inflation  of  the  tvmjianum,  cither  by  Polit- 
zer's  method  or  bv  the  introduction  of  the  catheter,  is  followed 
by  immediate  dizziness,  due  to  the  sudden  disturbance  of  lab\- 
rinthine  pressure.  No  judgment  can  be  formed  beforehand 
concerning  the  likelihood  of  this  occurrence.  It  is  alwavs 
well  when  the  procedure  is  conducted  for  the  first  time  to 
begin  the  inflation  very  gently,  allowing  but  little  air  to  enter 
the  tympanum  at  first,  and  gradually  increasing  the  strength 
of  the  current  if  unpleasant  symptoms  do  not  supervene. 
The  dizziness,  which  is  sometimes  so  severe  that  the  patient 
falls  from  the  chair  and  becomes  unconscious  for  a  moment,  is 
terrifying,  but  not  dangerous.  Where  the  membrana  tym- 
pani  is  very  thin,  either  as  a  result  of  a  previous  inflammatorv 
process  with  the  subsequent  formation  of  cicatricial  tissue,  or 
from  atrophic  changes,  a  forcible  inflation  may  rupture  it.  It 
follows,  therefore,  that  the  use  of  Politzer's  method  or  cathe- 
terization should  be  preceded  by  an  inspection  of  the  drum 
membrane. 

The  Comparative  Value  of  Politzerization  and  Catheter- 
ization.—  lla\iiig  now  considered  these  two  methods  ot  forc- 
ing a  current  of  air  througii  the  Eustachian  tubes  antl  into  the 
middle  ear.  a  few  words  as  t(^  their  relative  value  mav  not  be 
out  of  place.  As  a  means  of  diagnosis,  inflaticMi  l)v  the  catheter 
is  always  preferable,  as  it  enables  the  surgeon  to  estimate  the 
force  nccessarv  to  propel  the  air  through  the  canal,  to  observe 
the  effect  upon  the  auscultation  sounds  resulting  fiom  varia- 


CATHETERIZATION  COMPARED  W  iril   POLITZERIZATION.  131 

tions  in  the  strength  of  the  air  current,  and  to  repeat  the  ex- 
periment as  often  as  he  may  desire.  Moreov'er,  success  or 
failure  in  accomplishing  the  end  lies  entirely  in  the  hands  of 
the  operator  if  the  catheter  is  employed,  while  when  the  air 
bag  is  used  by  Folitzer's  method,  the  success  or  failure  lies 
quite  as  much  with  the  patient  as  with  the  surgeon,  as  it  de- 
pends upon  his  ability  completely  to  close  the  naso-pharvn- 
geal  space  by  elevation  of  the  soft  palate. 

In  the  adult  the  auscultatory  sounds  are  so  weak  when  Fo- 
litzer's method  is  used  that  very  little  information  is  gained 
by  using  the  diagnosis  tube.  In  children  under  twelve  vears 
of  age,  however,  the  Eustachian  canal  is  quite  short,  and  its 
calibre  comparatively  large  in  proportion  to  its  length.  At 
this  age  catheterization  is  somewhat  difficult,  while  the  air  bag 
htted  with  a  jtroper  nose  piece  usually  opens  the  tube  per- 
fectly, and  the  sounds  produced  within  the  tvm|)anum  are  suf- 
hciently  strong  to  be  perceived  through  the  diagnosis  tube. 

As  a  diagnc;stic  measure,  then.  Folitzer's  method  should 
be  used  in  voung  children  antl  in  those  cases  where  the  nasal 
passages  are  obstructed  to  such  an  extent  that  the  introduc- 
tion of  the  catheter  is  well-nigh  imp(»ssible. 

As  a  therapeutic  measure  the  catheter  is  decidedlv  supe- 
rior to  Folitzer's  method,  allowing  as  it  does  the  inflation  of 
either  ear  without  disturbing  the  organ  of  the  opposite  side 
and  permitting  the  application  of  various  medicated  vapors 
directlv  to  the  membrane  of  the  tube  and  tympanum,  without 
bringing  them  in  contact  with  the  mucous  membrane  of  the 
nasal  cavitv. 

When  Folitzeration  must  be  employed  from  necessity,  the 
action  of  the  air  may  be  confined  to  one  ear  by  the  insertion 
of  the  finger  into  the  opposite  meatus,  thus  compressing  the 
air  in  the  canal  and  rendering  anv  appreciable  outward  dis- 
j)lacement  of  the  membrana  tvmpani  impossible.  The  ad- 
vantage of  catheterization,  mentioned  in  comparing  the  two 
methods  for  diagnostic  purposes,  holds  good  in  this  connec- 
tion as  well — that  catheter  inflation  allows  an  exact  gradua- 
tion of  the  force  employed,  the  bulb  being  pressed  more  or 
less  strongly  as  indicated  by  the  freedom  with  which  the 
air  passes  into  the  middle  ear.  The  objection  so  frequently 
raised  against  catheterization — that  the  instrument  inflicts  a 
certain  amount  of  traumatism  on  the  structures  against  which 
it  impinges — need   scarcely  be  mentioned.     It  is  quite   true 


132  PHYSICAL   EXAMINATION. 

that  harsh  catheterization  always  does  -more  damage  than 
good,  but  harsh  catheterization  is  never  to  be  employed,  for, 
as  before  stated,  the  exercise  of  care  will  enable  even  the  be- 
ginner to  introduce  the  instrument  without  inflicting  any  in- 
jury, even  if  he  is  not  successful  in  directing  the  instrument 
into  the  pharvngeal  orifice  of  the  tube. 

The  Examination  of  the  Nose,  Naso-pharynx,  and  Phar- 
ynx.—  Under  no  circumstances  should  tlic  surgeon  consider 
his  physical  examination  complete  until  he  has  inspected  the 
regions  above  mentioned  which,  by  their  anatomical  position, 
exert  a  powerful  influence  upon  the  ear  both  in  health  and  in 
disease. 

As  the  mucous  membrane  lining  the  nasal  cavities  and  the 
naso-pharvngeal  space  is  continuous  with  tliat  lining  the  mid- 
dle ear,  an  intimate  relation  exists  between  the  nerve  and 
blood  supjilv  of  the  two  regions,  rendering  tiie  car  particu- 
larly susceptible  to  reflex  disturbances  depending  ujjun  some 
intranasal  exciting  cause,  as  well  as  to  circulatorv  changes 
from  alterations  in  the  blood  and  Ivmph  current  within  cither 
the  nasal  chambers  or  the  pharyngeal  vault.  After  a  satis- 
factory otoscopic  examination  has  been  made,  the  next  step 
should  be  to  inspect  the  oral  cavity  by  means  of  reflected 
light,  observing  the  condition  of  the  mucous  membrane  in 
the  mouth  ;  the  presence  of  carious  teeth  ;  the  appearance  of 
the  posterior  pharyngeal  wall,  whether  it  is  div  or  moist; 
whether  it  presents  the  smooth,  velvety  appearance  of  a  nor- 
mal mucous  membrane,  or  is  studded  here  and  there  with 
irregular  elevations,  indicative  of  the  presence  of  small  lymph 
nodules  just  beneath  its  superficial  epithelial  lavcr  In  this 
connection  attention  need  scarcely  be  called  to  the  importance 
of  observing  those  two  large  masses  of  lymphoid  tissue  situ- 
ated between  the  pillars  of  the  fauces — that  is,  the  faucial  ton- 
sils. Under  normal  conditions  the  tonsils  do  not  project  be- 
yond the  faucial  pillais.  and  special  effort  must  be  made  to  see 
them  in  a  condition  of  perfect  health,  bv  crowding  the  ante- 
rior faucial  pillar  against  the  lateral  wall  of  the  pharvnx,  or 
turning  the  head  of  the  patient  first  to  one  side  and  then  to 
the  other,  to  permit  the  observer  to  look  obliquely  across  the 
cavity  of  the  mouth,  in  order  that  they  may  be  brought  into 
view.  Anv  projection  of  these  bodies  beyond  the  pillars  of 
the  fauces  constitutes  an  abnormitv. 

The  vault  of  the  pharynx  next  demands  investigation.     In 


EXAMINATION    OF    THK    L'PrER    AIR    PASSAGES.         133 

very  young  children  posteri(jr  rhinoscopy  is  impossible,  and 
here  resort  may  be  had  to  digital  examination.  In  this  pro- 
cedure the  mouth  of  the  patient  should  be  held  open  by  a  cork 
inserted  far  back  between  the  jaws,  or  better  by  the  use  of  a 
mouth  gag.  The  index  finger,  with  the  palmar  surface  down- 
ward, should  then  be  introduced  into  the  opposite  angle  of  the 
mouth.  It  should  then  be  passed  rapidly  along  the  dorsum 
of  the  tongue  until  it  meets  the  posterior  pharyngeal  wall, 
when,  by  quickly  turning  the  palmar  surface  upward,  it  is 
passed  behind  the  soft  palate  into  the  naso-pharyngeal  space, 
the  palate  yielding  readilv  to  gentle  but  firm  traction.  By 
drawing  the  finger  forward  the  nasal  septum  should  now  be 
recognized  and  ftjUowed  upward  until  the  roof  of  the  cavity 
is  felt.  The  sensation  imparted  to  the  examining  digit  should 
be  observed:  whether  the  membrane  is  soft  and  spongy,  in- 
dicative of  the  f)rcscnce  of  an  abnormal  amoimt  of  Ivmphatic 
tissue,  or  whether  it  differs  but  little  from  the  sensation  im- 
parted bv  the  mucous  membrane  covering  the  posterior  wall 
of  the  oro-pharvnx.  These  facts  having  been  determined,  the 
tip  of  the  finger  is  turned  first  to  one  side  and  then  to  the 
other,  and  easilv  appreciates  the  luistachian  jnomincnces, 
after  which  it  is  withdrawn  ;  by  sweeping  along  the  posterior 
wall  of  the  naso-pharvnx  in  making  its  exit,  the  presence  of 
any  abnormal  amount  of  lymphoid  tissue  in  tin's  location  is 
determined. 

The  presence  of  adenoid  tissue  in  the  vault  (j1  the  piharynx 
afTects  the  ear  in  two  ways.  If  the  mass  is  large,  by  direct 
pressure  upon  the  Eustachian  orifice  the  supi»ly  of  air  in 
the  tympanic  cavity  mav  be  disturbed.  This  fact  will  be  ap- 
preciated by  reference  to  Fig.  50.  It  is  evident  that  the  en- 
larged pharyngeal  tonsil,  seen  in  this  drawing,  lies  so  closely 
to  the  posterior  lip  of  the  tube  that  any  increase  in  volume 
would  interfere  with  the  patency  of  the  canal.  Any  slight  in- 
crease in  volume  of  the  mass  will  close  the  lumen  of  the  tube, 
after  which  the  intratvmpanic  air  is  gradually  absorbed  by 
the  blood  which  circulates  through  vessels  in  the  walls  of 
the  cavitv.  With  each  act  of  swallowing,  at  which  time  the 
tube  opens  momentarilv,  the  air  is  aspirated  into  the  naso- 
pharynx, the  tube  closing  so  quickly  that  the  passage  of  air 
into  the  tvmpanum  does  not  take  place.  In  this  manner  a 
passive  congestion  of  the  mucous  membrane  of  the  middle 
ear  is  produced,  a  condition  which  constitutes  practicalh-  the 


134  PHYSICAL   EXAMINATlOxN. 

first  stage  of  an  inflammation,  and,  if  long  continued,  results 
in  permanent  tissue  changes. 

I  am  inclined  to  think  the  more  important  manner  in 
which  adenoid  growths,  especially  those  of  moderate  size, 
affect  the  organ  of  hearing  is  by  the  obstruction  to  the  ve- 
nous return  current  from  the  tympanum  and  labyrinth.  It 
must  not  be  forgotten  that  the  pharyngeal  tonsil  constitutes 
nothing  more  than  a  lymphatic  gland,  and,  in  virtue  of  its 
presence,  may  exert  sufficient  pressure  to  partially  obstruct 
the  venous  flow  from  the  tympanic  cavity.  Any  condition 
which  affects,  for  a  considerable  period,  the  circulation  within 
the  middle  ear,  will  also  cause  a  disturbance  of  the  labyrin- 
thine circulation  from  an  alteration  in  the  tension  of  the  fluid 
contained.  Such  changes  in  the  labyrinth,  however  slight, 
render  this  portion  of  the  economy  particularly  susceptible  to 
inflammation,  cither  as  the  result  of  infection  or  of  mechan- 
ical irritation,  the  most  fruitful  source  of  the  latter  being  the 
crowding  inward  of  the  ossicular  chain  by  atmospheric  pres- 
sure, when  the  tension  of  the  air  within  the  tympanum  is  re- 
duced. Evidence  is  not  wanting,  from  a  clinical  point  of 
view,  that  even  in  very  early  life  the  labyrinth  may  be  af- 
fected by  the  presence  of  growths  of  this  kind.  We  not  un- 
commonly find  instances  of  tubal  catarrh  in  children  in  whom 
these  growths  are  present;  instead  of  presenting,  upon  func- 
tional examination,  the  reactions  characteristic  of  the  affec- 
tion, these  cases  show  a  diminution  of  bone  conduction,  and 
sometimes  a  hyperaesthetic  condition  of  the  auditory  nerve, 
both  of  which  phenomena  indicate  an  irritative  lesion  of  the 
labyrinth.  In  very  young  children  it  is  of  the  utmost  impor- 
tance to  determine  the  presence  or  absence  of  a  growth  of 
this  kind,  even  where  the  history  seems  to  show  that  the  child 
is  entirely  deaf,  for,  as  articulate  speech  is  acquired  simply 
by  imitation,  an  impairment  of  audition  which  in  an  adult  or 
in  a  child  of  a  few  years  of  age  would  be  practically  insig- 
nificant, in  a  child  so  young  that  the  function  of  audition  has 
never  been  exercised,  may  give  rise  to  all  the  symptoms  usu- 
ally found  in  a  deaf-mute.  , 

The  oro-phar\'nx  and  the  pharyngeal  vault  having  been 
examined  in  the  manner  stated,  attention  should  next  be  di- 
rected to  the  anterior  nares.  The  nasal  cavity  should  be 
inspected  by  anterior  rhinoscopy,  the  tip  of  the  nose  being 
tilted  up  by  means  of  the  thumb  of  the  left  hand,  the  hngers 


EXAMINATION    OF   THE    UPPER    AIR    PASSAGES. 


135 


of  the  hand  resting  upon  the  forehead  for  support,  while  the 
nasal  orifice  is  dilated  gently  with  a  self-retaining  speculum 
(Fig.  54).  The  patient's  head  should  be  flexed  slightly  for- 
ward, in  such  a  position  that  the  floor  of  the  nasal  cavity  will 
be  nearly  horizontal.  When  the  light  from  the  head  mirror 
is  directed  into  the  cavity 
the  observer  inspects  first 
the  inferior  meatus,  and 
remarks  if  any  deformitv 
of  the  septum  is  present, 

]    ,  •    •         -x.  »       ^  10  Ilti-  54- — Bosworth's  nasal 

determming  Its  extent,  na-         Ij  speculum. 

ture,  and  location,  as  well 

as  the  size,  shape,  and  color,  of  .the  inferior  turbinated  body  ; 
whether  it  is  turgescent  and  occludes  the  inferior  meatus  to  a 
considerable  extent,  or  whether  its  mucous  membrane  is  of 
the  normal  light  rosv  tint,  and  its  rich  venous  plexuses  are 
not  abnormallv  engorged.  Under  normal  conditions,  where 
no  deformity  of  the  septum  exists  and  the  turbinated  tissue  is 
not  swollen,  the  observer  can  readily  see  the  posterior  wall  of 
the  naso-j)harvnx  bv  anterior  rhinoscopv,  and,  in  fact,  the  au- 
thor has  found  this  one  of  the  most  simple  methods  of  deter- 
mining the  presence  of  hvpcrtroj)hicd  Ivmphatic  tissue  in  this 
region.  This  portion  of  the  examination  is  rendered  more 
complete  if  a  weak  solution  of  cocaine  is  sprayed  into  the  an- 
terior nares.  before  an  attem[)t  is  made  to  inspect  the  naso- 
pharynx in  this  manner.  The  ana.thesia  this  produces  renders 
it  the  simplest  possible  procedure  to  add  to  our  information 
bv  touching  the  various  parts  under  inspection  with  a  cotton- 
tipped  probe  passed  through  the  anterior  nares.  The  inspec- 
tion of  the  lower  meatus  and  naso-pharynx  having  been  com- 
pleted, the  head  is  now^  tilted  backward,  and  the  observer  di- 
rects his  attention  to  the  uppter  part  of  the  nasal  chamber.  In 
the  anterior  portion  the  eye  recognizes  readily  the  tip  of  the 
middle  turbinated  bod}',  which,  normally,  is  of  a  somew^hat 
lighter  color  than  the  lower  turbinate  and  less  freely  supplied 
with  venous  channels,  for  which  reason  its  mucous  membrane 
seems  to  be  more  closely  applied  to  the  bon}-  framework,  the 
entire  structure  projecting  less  into  the  lumen  of  the  passage 
than  does  the  inferior  turbinate.  Any  deviation  from  this 
normal  appearance  should  be  carefully  noted  as  constituting 
a  source  of  obstruction  to  nasal  respiration.  It  should  be  re- 
meinbered  that  the  furrow  or  hiatus  beneath  the  middle  tur- 


136 


PHYSICAL    EXAMINATION. 


binated  body  contains  the  opening  of  the  frontal,  anterior, 
ethmoidal,  and  maxillary  sinuses;  consequently  it  should  be 
inspected  with  special  care  for  the  presence  of  a  j)urulent  dis- 
charge which,  when  lying  here,  is  almost  pathognomonic  of 
an  inflammation  of  one  of  these  accessory  cavities.  This  also 
is  the  region  from  which  nasal  polypi  most  frequently  take 
their  origin,  and  the  possible  presence  of  these  growths  must 
always  be  borne  in  mind  during  this  stage  of  the  examination. 

We  have  spoken  only  of  the  hypertrophic  condition,  since 
this  is  the  lesion  usually  presented  in  cases  which  come  under 
the  observation  of  the  otologist.  It  must  be  remembered,  how- 
ever, that  precisely  the  opposite  state  of  affairs  may  constitute 
a  morbid  condition — that  is,  instead  of  an  hypertrophy  of  the 
lining  membrane,  this  may  be  abnormally  thin,  the  turbinated 
bodies  lying  close  to  the  outer  wall  of  the  passage  and  project- 
ing but  little  into  the  lumen.  When  the  condition  is  extremely 
well  marked,  they  are  discernible  with  some  difficulty.  Under 
these  circumstances  the  mucous  membrane,  instead  of  being 
moist,  has  a  dry,  glazed  appearance,  while  in  the  sulci  be- 
tween or  beneath  the  turbinated  bodies,  large  greenish-yellow 
crusts  are  seen.  These  result  from  the  inspissation  of  the  nasal 
secretion,  which,  owing  to  the  atrophy  of  the  lining  mem- 
brane, is  wanting  in  fluidity.  The  naso-pharynx  also,  instead 
of  showing  the  presence  of  lymphatic  tissue,  may  appear 
glazed,  and  may  be  covered,  to  a  greater  or  less  extent,  with 
a  thick,  tough  mucus,  usually  in  the  form  of  a  scale  or  shell, 
which  spreads  irregularly  in  all  directions  from  the  median 
line.  This  naso-pharyngeal  condition  is  seldom  found  before 
the  age  of  twenty,  and  is  usually  due  to  retrograde  changes  in 
the  lymphoid  tissue  of  the  region,  which  in  early  life  had  un- 
doubtedly been  moderately  but  not  excessively  hypertrophied. 
Instead  of  disappearing  completely  after  the  age  of  puberty, 
as  is  often  the  case,  interference  with  this  retrograde  process 
occurred  for  some  reason,  with  the  result  that  the  fibrous 
elements  of  the  pharyngeal  tonsil  persisted  and  increased  in 
density,  while  the  cellular  elements  disappeared.  This  local 
condition  constitutes  the  lesion  in  the  cases  of  so-called  naso- 
pharyngeal catarrh,  or  chronic  naso-pharyngitis.  The  ap- 
pearance described  can  be  recognized  both  by  the  anterior 
rhinoscopic  examination,  and  by  posterior  rhinoscopy  as  well. 

By  posterior  rhinoscopy  we  are  enabled  to  obtain  a  view 
of  those  structures  which  are  hidden  from  direct  inspection 


EXAMINATION    OF    THE    UPPER    AIR    PASSAGES. 


137 


by  the  curtain  of  the  soft  palate.  This  is  accomplished  by 
means  of  a  mirror  introduced  into  the  mouth,  with  the  reflect- 
ing surface  directed  upward,  so  that  the  image  of  the  region 
in  question  is  reflected  in  the  mirror.  In  order  to  conduct 
this  examination  the  patient  is  seated  facing  the  surgeon,  the 
arrangement  of  the  light  and  the  relative  positions  of  the  pa- 
tient and  operator  being  the  same  as  those  already  given  un 
der  the  description  of  otoscopy.  The  head  of  the  patient  is 
inclined  very  slightly  forward  so  that  the  hard  palate  lies  in 
the  horizontal  plane.  The  surgeon  now  depresses  the  tongue 
with  the  tongue  depressor  held  in  the  left  hand,  crowding  the 
organ  downward  while,  at  the  same  time  the  instrument  is 


Fig.  55.  —  B.jsworth's  tongue 
depressor. 


Fig.  56. — Folding  tongue  depressor. 


Fig.  57. — TUrck'.s  tongue  depressor. 


rotated  slightly  by  elevating  the  handle,  the  blade  resting 
upon  the  incisor  teeth,  thus  exerting  slight  forward  traction. 
In  this  way  efforts  at  retching  on  the  part  of  the  patient  are 
avoided,  as  the  base  of  the  tongue,  instead  of  being  crowded 
into  the  throat,  a  circumstance  which  always  results  in  ex- 
citing an  efTort  of  deglutition,  is  drawn  forward  out  of  the 
pharynx.  The  patient  is  directed  to  breathe  quietly,  and 
at  an  opportune  moment,  when  the  palatal  muscles  are  re- 
laxed and   the  velum   hangs  vertically  downward,  the  rhino- 


,.8  PHYSICAL   EXAMINATION. 

scopic  mirror,  previously  slightly  warmed  over  the  lamp,  is 
carried  rapidly  into  the  mouth  and  made  to  assume  a  position 
to  the  one  side  or  the  other  of  the  uvula.  The  rays  of  light 
from  the  head  mirror  are  directed  upon  the  surface  of  the 
rhinoscopic  mirror,  which,  as  the  inclination  of  its  polished 
surface  is  about  one  hundred  and  thirty-five  degrees,  directs 
the  rays  impinging  upon  it  into  the  retronasal  space.     At  first 


0 


Fig.  5S. — Rhinoscopic  mirror. 


the  handle  of  the  mirror  should  be  carried  slightlv  downward, 
which  brings  into  view  the  posterior  margin  of  the  nasal  sep- 
tum ;  this  should  be  followed  upward  until  its  narrow  edge  is 
seen  gradually  to  broaden  and  finally  to  disappear  in  the  ujiper 
wall  of  the  naso-pharvnx.  In  bringing  the  septum  into  view 
the  presence  of  an  hypertrophied  posterior  extremity  of  either 
lower  turbinated  bodv  will  easily  be  recognized  by  its  marked 
encroachment  upon  the  lumen  of  the  corresponding  posterior 
nasal  orifice.  In  the  same  manner  mvxomatous  growths, 
springing  from  the  nasal  cavities  and  extending  into  the  naso- 
pharvngeal  space,  will  also  be  easily  discovered.  Any  in- 
crease in  the  Ivmphatic  tissue  near  the  pharvngeal  roof  will 
be  at  once  evident,  as  its  presence  renders  it  impossible  fc^r 
the  observer  to  follow  the  outline  of  the  septum  upward  to 
where  the  divergent  edges  are  lost  in  the  pharyngeal  roof 
the  expanded  portion  of  the  septum  being  concealed  bv  the 
hvpcrtrophied  Ivmphatic  tissue.  By  graduallv  elevating  the 
handle  of  the  mirror  the  entire  roof  and  a  portion  of  the 
posterior  wall  of  the  naso-pharvnx  are  brought  into  view, 
and  by  rotation  of  the  mirror  upon  the  long  axis  of  the  shatik 
each  lateral  wall  of  the  cavity  is  inspected  and  the  prominent 
posterior  lip  of  the  Eustachian  tube  upon  either  side  easily 
recognized.  Behind  this  we  observe  the  fossa  of  Rosenmiil- 
ler,  while  in  front  is  the  orifice  of  the  Eustachian  tube,  wiiich 
varies  in  shape  from  a  slitlike  depression,  to  an  opening  with 
distinctly  circular  borders.     (Fi(;s.  49-51.) 

PRErARATK^N    OF    InSTRUMKXT.S. 

Before  concluding  the  subject  of  the  physical  examination, 
a  few  words  will  not  be  out  of  place  concerning  the  care  of 
instruments  used  in  conducting  the  examination.     Too  much 


PREPARATION    OF    INSTRUMENTS. 


139 


Stress  can  not  be  laid  upon,  the  necessity  of  absolute  asepsis. 
All  metal  instruments  should  be  sterilized  by  boiling  in  a  two- 
per-cent  sodium-bicarbonate  solution  before  each  examina- 
tion. If  rubber  catheters  are  to  be  used,  each  patient  should 
possess  his  own  instrument,  while  if  silver  catheters  are  used 
they  should  be  sterilized  in  the  manner  above  ^described. 

In  cleansing  the  ear  with  a  syringe,  an  aseptic  solution  or, 
better  still,  an  antiseptic  solution  should  always  be  employed. 
A  solution  of  bichloride  of  mercury  in  the  proportion  of  i  to 
5,000  is  sufficiently  antiseptic  to  prevent  infection  of  the  tym- 
panic cavity  if  the  drum  membrane  is  accidentally  perforated 
during  the  process  of  cleansing  the  canal.  The  tip  of  the  ear 
syringe  should  be  boiled  immediately  before  use,  or,  if  this  is 
not  convenient,  the  extremity  should  be  covered  by  a  small 
piece  of  soft-rubber  tubing,  which  is  renewed  each  time  the 
syringe  is  used. 

As  the  prolonged  boiling  of  tenijiered  instruments  is  inju- 
rious, these  may  be  thoroughly  cleansed  with  cotton  and  then 
dipped  for  a  moment  in  the  boiling  soda  solution,  alter  which 
they  are  immersed  in  a  five-per-cent  solutii^n  of  carbolic  acid 
for  several  minutes. 

It  is  scarcely  necessary  to  call  attention  to  the  necessity 
of  personal  cleanliness  on  the  part  of  the  operator,  and  yet 
perhaps  this  is  occasionally  forgotten. 

These  measures  have  been  recommended  by  many  writers 
to  avoid  specific  infection  chiefly.  In  this  coimtrv,  where 
specific  disease  is  not  as  common  as  upon  the  Continent,  the 
above  precautions  are  scarcely  necessary  for  this  purpose, 
but  they  are  necessary  to  prevent  purulent  infection  of  the 
middle  ear. 

If  the  above  precautions  are  adopted  in  every  case,  the 
extent  to  which  operative  procedures  within  the  middle  ear 
can  be  carried  is  surprising.  In  no  region  of  the  body,  per- 
haps, is  asepsis  more  important,  and  nowhere  certainly  has 
it  been  so  utterly  disregarded. 

Thf.  History. 

A  very  important  part  in  the  intelligent  investigation 
of  any  affection  of  the  ear,  involving  a  partial  loss  or  per- 
version of  its  function  is  the  general  history  of  the  patient, 
together  with  an  exact  account  of  the  aural  affection.  It 
is  scarcely  necessary  to  give  more  than  briefly  the  various 


140 


PHYSICAL   EXAMINATION. 


subjects  which  should  be  investigated,  before  any  decided 
opinion  is  given  as  to  the  nature  of  the  affection  or  the  prob- 
able course  which  it  will  pursue.  These  facts  influence  our 
opinion  not  only  as  to  the  favorable  or  unfavorable  progress 
of  the  disease,  but  in  no  small  degree  enable  us  to  determine 
the  relative  value  of  the  various  data  with  which  our  physical 
and  functional  examinations  furnish  us.  The  age  of  the  pa- 
tient, the  occupation,  and  the  habits  of  life  should  be  first  con- 
sidered. The  history  of  any  previous  illness  must  be  investi- 
gated with  great  care,  particularly  concerning  the  occurrence 
in  childhood  of  anv  of  the  exanthemata  and  other  kindred 
diseases,  and  later  in  life  of  any  of  the  continued  fevers.  A 
not  unimportant  factor  is  the  presence  of  an  hereditary  taint 
— tuberculous,  specific,  gouty,  or  rheumatic — as  well  as  the 
existence  of  chronic  aural  disease  in  any  other  members  of  the 
family.  The  habits  of  the  patient  regarding  the  use  of  opiates, 
stimulants,  tobacco,  indulgence  in  the  luxuries  of  the  table, 
or  the  fact  of  his  having  been  called  upon  at  any  time  to 
undergo  severe  mental  strain  or  physical  exertion,  must  also 
receive  consideration.  Special  attention  should  also  be  paid 
as  to  whether,  at  any  period  of  life,  it  has  been  necessary  for 
him  to  take  continuously  large  doses  of  the  various  drugs  which 
arc  known  to  have  a  specific  action  on  the  auditory  organs. 

Next  the  status  pncscns  should  receive  attention,  particu- 
larly with  reference  to  the  digestive  system,  and  here  it  must 
not  be  forgotten  that  the  mouth  is  responsible  for  quite  as 
much  aural  disturbance  as  the  stomach,  and  inquiry  should 
be  made  into  the  condition  of  the  teeth.  Any  previous  or 
present  condition  referable  to  the  pelvic  organs  must  also  be 
inquired  into.  Much  information  may  frecpicntly  be  obtained 
by  observing  the  general  behavior  of  the  subject  in  respond- 
ing to  the  various  questions,  it  being  remembered  that,  in 
patients  of  a  decidedly  neurotic  tendency,  care  must  be  ob- 
served in  the  interpretation  of  the  apparent  results  obtained 
by  a  functional  examination,  the  mere  fact  that  they  are  under 
examination  often  disturbing  them  to  such  a  degree  that  their 
answers  are  entirely  imtrustworthv. 

When  we  C(^me  to  the  special  history — that  is,  that  part 
which  bears  dirccth'  upon  the  aural  affection  for  whicii  they 
seek  advice — the  length  of  time  which  this  has  existed  must,  if 
possible,  be  determined.  It  is  of  special  imjtortance  to  inquire 
into  the  condition  of  the  cars  in  childhood,  as  not  infrequently 


THE    HIST(M<V.  141 


0 


the  patient  mav  ncij^lect  to  state  the  presence  of  aural  symp- 
toms in  early  life,  conceivini^  that  as  these  have  apparently 
disappeared,  they  can  have  no  bearing  upon  the  present 
affection.  The  symptoms  upon  which  the  patient  lays  most 
stress  generally,  are  impairment  of  hearing,  tinnitus,  discharge 
from  the  ear  or  pain  in  this  location.  Nausea,  vertigo,  general 
headache,  etc.,  may  have  a  very  important  bearing  upon  the 
malady,  yet  may  be  referred  by  the  patient  to  entirelv  differ- 
ent causes  and  hence  remain  immentioned  unless  he  is  ques- 
tioned especially  with  reference  to  their  previous  existence. 
If  the  affection  has  been  of  long  duiation  it  is  of  the  greatest 
importance  to  discover  whether  the  j)rogrcss  has  been  unin- 
terrupted, or  whether  under  certain  conditions  it  has  been 
aggravated.  In  this  connection  the  effect  upon  the  ear  of  an 
acute  inflammatory  condition  of  the  mucous  membrane  lining 
the  nose  or  naso-])harvn\',  or  of  an  aggravation  of  already  ex- 
isting catarrhal  disturbances,  is  to  be  discovered,  the  intimate 
relation  between  the  uj)per  air  tract  and  the  organ  of  hearing 
rendering  this  of  great  moment.  It  mav  be  taken  as  an  almost 
invariable  rule  where  the  aural  svmptoms  are  intermittent 
in  character,  becoming  more  severe  when  the  patient  suffers 
from  a  cold  in  the  head,  that  even  if  the  pathological  process 
is  located  in  the  middle  ear,  our  treatment  must  be  directed 
quite  as  much  to  the  upper  air  passages  as  to  the  tvmpanum 
itself  in  order  to  obtain  jiermanent  benefit. 

If  the  prominent  svmptom  is  an  imj)airmcnt  of  hearing  or 
the  presence  of  tinnitus  we  should  discover  under  what  con- 
ditions these  are  most  troublesome — whether  the  patient  hears 
better  in  a  noisv  or  in  a  quiet  ])lace  ;  whether  the  chief  diffi- 
culty is  that  it  is  im])ossible  to  understand  general  conversa- 
tion, or  whether  the  impairment  is  so  marked  that  even  dia- 
logue is  imj^ossible.  Ascertaining  the  particular  time  during 
the  day  when  the  disturbance  is  most  severe — whether  in  the 
morning,  after  a  refreshing  night's  sleep,  or  at  the  end  of  the 
day,  when  tired  both  physically  and  mentally — may  often  aid 
us  in  forming  our  opinion.  A  word  of  caution  should  be 
added  lest  the  physician  may,  by  attaching  too  much  impor- 
tance to  any  one  symptom,  cause  the  patient  to  exaggerate  it 
unduly.  This  is  especially  true  in  questioning  him  concern- 
ing his  tinnitus.  If  distressing,  he  will  complain  of  it  without 
interrogation,  but  if  this  is  not  the  case,  only  the  most  casual 
mention  should  be  made  regarding  its  presence. 


CHAPTER   IV. 

FUNCTIONAL    EXAMINATION. 

As  the  aural  surgeon  is  consulted  most  frequently  on  ac- 
count of  either  impairment  or  perversion  of  function  in  the 
auditory  apparatus,  it  would  seem  natural  that  he  could  arrive 
at  the  most  perfect  conception  of  the  condition  of  this  appa- 
ratus by  testing  the  functional  condition  of  the  organ  of  hear- 
ing. It  is  strange,  however,  that  while  much  attention  has 
been  paid  to  the  observation  of  physical  changes  in  the  ex- 
ternal and  middle  ear,  which  may  be  noted  by  ocular  inspec- 
tion, the  functional  examination  has  ordinarily  been  conducted 
in  the  most  superficial  manner. 

Bv  recalling  the  remarks  made  under  Physiology,  it  will 
be  remembered  that  the  ear  perceives  not  only  the  intensity 
of  a  sound,  but  also  its  pitch  or  quality ;  consequently  a 
functional  examination  is  comj)lete  only  when  it  estimates 
both  the  (jualitatiye  and  quantitative  condition  of  audition. 

I.  Quantitative  Tests. — In  order  to  determine  how  much 
the  quantitative  function  of  the  car  is  impaired,  it  is  only 
necessary  to  compare  the  distance  at  which  any  given  sound 
is  heard  by  the  ear  under  examination,  with  the  distance  at 
which  it  is  perceived  by  the  normal  ear. 

For  convenience,  the  hearing  power  is  ordinarily  ex- 
pressed as  a  fraction,  the  denominator  of  which  represents 
the  distance  in  feet  or  inches  at  which  the  sound  is  normally 
heard,  while  the  numerator  designates  the  distance  at  which 
the  sound  is  perceived  in  the  affected  ear  under  examination. 

It  should  be  borne  in  mind  that  as  a  single  sound  excites 
only  one  part  of  the  perceptive  apparatus,  an  ear  which  may 
be  perfectly  healthy  otherwise  may  fail  to  perceive  one  sound 
on  account  of  the  destruction  of  this  particular  area  in  the 
cochlea,  and  in  order  to  apply  this  test  we  must  be  certain 
that  the  perceptive  mechanism  will  respond  to  the  particular 
standard  sound  to  be  employed  as  a  unit.     In  order  that  the 

(142) 


QUANTITATIVE    TESTS.  I43 

results  of  various  observers  may  be  compared,  use  must  also 
be  made  of  a  sound  of  a  given  quality  and  intensitv  ;  and 
herein  lies  one  of  the  chief  difficulties  of  comparing  the  re- 
sults of  tests  made  by  different  observers. 

The  sound  most  commonly  employed  in  making  a  quant i 
tative  test,  where  the  hearing  is  but  moderately  impaired,  is 
the  tick  of  the  watch.  While  this  may  be  fairlv  accurate  in 
observations  made  by  the  same  individual,  it  is  manifestlv 
impossible  that  any  comparison  of  results  reached  by  several 
examiners  can  be  made.  To  obviate  this  difficult v,  Politzer* 
devised  the  instrument  shown  in  Fig.  59,  which  is  supposed 
to  produce  a  sound  whose  intensity  and  oualitv  are  ahvavs 
the  same.  This,  perhaps,  is  the  most  uni- 
versally used  apjiaratus  for  conducting 
experiments  of  this  kind.  The  chief  ob- 
jection is  that  as  the  sound  produced  bv 
the  instrument  is  heard  bv  the  normal 
ear  at  a  distance  of  fortN-five  feet,  its 
use  is  restricted  to  those  cases  in  which 

,        .  .  ,    ,  .  .  .  ,  1"  IG.  59. —  I'olitzcr's  acou- 

thc  mipairment  ol   hearmg  is  considcra-  metci. 

blc.     Moreover,  it  is  not  impossible  that 

the  particular  portion  of  the  {perceptive  aj^jiaratus  which  is 
responsive  to  this  sound  mav  be  so  alfccted  that,  while  the 
function  of  the  organ  as  a  whole  may  imjirovc,  the  distance 
at  which  this  sound  is  perceived  may  remain  unchanged. 

The  ideal  test  in  estimating  impairments  of  audition  is 
the  human  voice,  since  the  patient  desires  especially  that 
the  power  of  audition  for  sounds  thus  produced  shall  be  im- 
proved, and,  moreover,  because  his  own  estimate  of  the  prog- 
ress of  his  disease  is  very  largely  based  upon  the  ease  or  diffi- 
culty with  which  he  is  able  to  understand  the  human  voice 
in  ordinarv  conversation.  Therefore,  no  matter  what  me- 
chanical appliance  may  be  used  in  estimating  the  power  of 
audition,  no  s^'stem  of  examination  is  complete  which  fails  to 
record  the  facility  with  which  various  vocal  sounds  are  per- 
ceived. Since  the  conversational  voice  varies  greatly  both 
in  pitch  and  intensity  in  different  individuals,  an  exact  com- 
parison of  the  results  obtained  bv  using  the  conversational 
voice  as  a  standard  would  be  difficult.  The  whisper,  how- 
ever, is  tairlv  constant  in  piitch  and  intensitv.  if  care  be  taken 

*  Archiv  fiir  Ohrinheilkunde,  vol.  xii,  p.  104. 


144 


FUNCTIONAL   EXAMINATION. 


that  in  every  examination  the  wliisper  shall  be  as  loud  as 
possible,  or  what  may  be  termed  "a  forced  whisper."  The 
examiner  in  carrying  out  this  test  should  first  fill  the  lungs  by 
a  forced  inspiration,  and  then  allow  them  to  empty  them- 
selv'es  by  a  normal  expiratory  effort,  after  which  he  should 
repeat  in  a  whispering  voice  the  particular  word  or  words  to 
be  used  as  the  test.  I  have  taken  pains  to  compare  the  data 
obtained  by  various  observers  by  tests  conducted  in  this 
manner,  and  find  that  the  error  of  experiment  is  very  small 
when  the  test  is  conducted  carefully.  It  should  be  remem- 
bered that  the  patient  soon  becomes  familiar  with  sentences 
used  in  these  experiments,  and  when  the  same  phrases  are 
repeated  frequently  the  results  obtained  are  worthless.  To 
avoid  this  result,  Siebenmann*  advises  the  use  of  numbers  of 
two  figures.  In  this  way  the  patient  can  not  become  familiar 
with  any  given  test  sentence,  as  the  same  numbers  are  not 
repeated  on  successive  examinations,  or  if  repeated,  their  se- 
quence is  changed.  We  meet,  however,  with  the  difficulty 
that  certain  combinations  of  letters  arc  more  casilv  perceived 
than  others,  even  when  whispered  with  the  same  intensity — 
in  other  words,  each  vowel  and  consonant  sound  possesses  an 
intensitv  i)cculiar  to  itself,  the  vowel  sounds  being  more  eas- 
ily heard  than  consonant  sounds.  This  characteristic  of  indi- 
vidual letters  is  denominated  their  logographic  value,  and  the 
appended  table,  prepared  by  Blake,  exhibits  the  relative  in- 
tensity of  the  consonant  sounds ;  the  T  sound  being  that  of 
the  greatest  intensity,  its  value  for  purposes  of  comparison  is 
denominated  in  the  table  as  lOO: 

T  =  loo  B  =  53  K  =  3i 

Z  =    63  D  =  45  L  =  2i 

C  =   62  S  =  40  N  =  1 1 

P=    58  F  =  35  M=   9 
G=  56 

If  proper  care  is  exercised  in  the  selection  of  numbers  of 
two  figures,  or  if  the  numbers  are  selected  at  random,  and 
the  average  results  of  ten  exjieriments  be  taken  as  represent- 
ing the  quantitative  value  of  the  hearing  in  anv  jiarticular  case, 
a  fairlv  accurate  estimate  of  the  condition  mav  be  obtained. 

Instead  of  estimating  the  distance  at  which  a  stnind   of 

*  Archives  of  Otolog)',  vol.  xxii,  p.  i. 


QUANTITATIVE   TESTS.  145 

known  intensity  is  heard,  another  fairly  accurate  method 
consists  in  comparini^  the  time  during  which  a  given  musical 
note  is  perceived  by  the  defective  organ,  with  the  perception 
time  of  the  normal  ear.  The  sounding  body  is  set  in  vibration 
by  a  constant  force,  and  the  relation  is  expressed  in  the  form 
of  a  fraction  of  which  the  normal  perception  time  is  the  de- 
nominator and  the  perception  time  of  the  defective  ear  ex- 
amined is  the  numerator.  While  not  absolutely  accurate  from 
a  mathematical  point  of  view,  the  error  is  so  slight  that  it 
mav  be  practically  disregarded,  as  proved  by  the  experiments 
ol  Barth.''  The  only  ditHculty  in  testing  in  this  manner  is  in 
obtaining  a  constant  force  for  setting  the  tuning  fork  or  any 
other  convenient  instrument  in  vibration.  If  each  examiner 
determines  his  own  standaid  experimentallv,  bv  estimating 
the  time  during  which  the  fork  is  heard  bv  the  normal  ear,  it 
being  set  in  vibration  bv  a  blow  which  habit  has  enabled  him 
to  make  fairlv  constant,  a  coniitarison  of  such  results  will  be 
perfectlv  possible  and  fairlv  accurate,  it  being  only  necessarv 
that  the  rate  of  vil)ration.  or  the  pitch,  oi  the  instrument  be 
known,  and  that  its  note  be  j)ure — that  is,  free  from  over- 
tones. The  note  usurdly  emploved  is  that  of  a  tuning  fork 
making  five  hundred  ami  twelve  V.  S.,  which  corresponds  to 
the  treble  C  of  the  musical  scale,  as  it  is  more  easy  to  con- 
struct an  instrument  of  this  pitch,  free  from  overtones,  than 
t)ne  of  lower  [)itch. 

It  is  scarcelv  necessarv  to  mention  the  more  comjilicated 
instruments  which  from  time  to  time  have  been  devised  for 
determining  quantitative  audition.  Their  use  has  never  be- 
come universal  on  account  of  their  complex  construction. 
The  phonograph,  supplied  with  a  series  of  standard  cylin- 
ders and  capable  of  reproducing  sounds  which  shall  always 
be  uniform  both  in  pitch  and  intensitv,  is  probablv  the  most 
simple  of  these  devices.  The  iirincij)le  of  the  telephone  has 
been  used  in  constructing  instruments  for  this  purpose.  Of 
these,  probably  that  recommended  bv  Urbantschitsch  +  is  the 
best.  The  operation  of  this  instrument  and  of  other  kindred 
devices  depends  upon  graduallv  diminishing  the  intensity  of 
a  given  sound  by  sliding  the  secondarv  coil  of  an  induction 
apparatus,  introduced  into  the  circuit,  over  the  primary  coil. 


*  Archives  of  Otolng}-,  vol.  xvii,  p.  153. 
f  Lehrbuch  dcr  Ohrenheilkiinde,  Vienna.  iSqo,  p.  39. 
II 


146 


FUNCTIONAL   EXAMINATION. 


The  sound  is  conveyed  to  the  ear  of  the  patient  by  means  of 
an  ordinary  telephone. 

In  the  instrument  shown  in  Fig.  60  the  sound  employed  is 
produced  by  the  rapid  interruption  of  the  electric  current  by 
Neef's  hammer.  It  is  necessary  that  the  vibrating  hammer 
be  completely  inclosed,  in  order  that  its  repeated  blows  may 
not  be  heard  throusfh  the  air  in  cases  where  the  hearing  is 


Fig.  60. — Urbantschitsch's  electric  acoumeter.  E,  Primary  battery  ;  A^,  Neefs  ham- 
mer for  interrupting  the  current  automatically,  and  thus  producing  the  sound  to 
be  employed  in  conducting  the  test  ;  2,  2',  Induction  coils  of  equal  size,  but 
wound  in  opposite  directions  ;  i,  Movable  helix  ;  T,  Telephone  ;  .S",  Screw  for 
moving  the  helix.  As  the  helix  is  withdrawn  from  one  secondary  coil,  it  enters 
the  other,  which  is  wound  in  the  opposite  direction,  and  the  intensity  of  the 
sound  heard  through  the  receiver  is  thus  increased  or  diminished  at  will.  (Ur- 
bantschitsch.) 

but  slightly  impaired,  or  by  the  opposite  ear,  where  there  is 
great  impairment  upon  one  side,  the  opposite  organ  being 
normal  or  nearly  so. 

A  somewhat  similar  instrument  has  been  devised  by  Gran- 
dinego*  in  which  the  source  of  sound  is  a  metal  rod  producing 
a  pure  musical  note  corresponding  to  C  in  the  musical  scale. 


*  Handbuch    der    Ohrenheilkunde    von    Schwartze,    Leipzig,     1S93,    vol.    ii, 
P-  383- 


QUANTITATIVE    TESTS.  147 

This  certainly  possesses  advantages  over  the  instrument  just 
described,  in  which  the  quality  of  the  sound  must  vary  con- 
siderably. 

The  maximal  phonometer  was  devised  by  Lucae*  to  meas- 
ure the  intensity  of  a  vocal  sound  by  observing  to  what  extent 
the  vibrating  column  of  air  displaced  a  diaphragm  upon  which 
it  was  made  to  impinge.  The  instrument  is  too  complicated 
to  be  used  universally. 

Whatever  method  is  adopted  in  making  a  quantitative  test, 
certain  precautions  must  be  taken  to  avoid  error  in  cases 
where  a  marked  impairment  of  hearing  exists  in  one  ear,  with 
only  a  very  slight  impairment  in  the  function  of  the  other. 
It  is  impossible  to  prevent  the  normal  ear  from  perceiving 
sounds  of  great  intensity,  no  matter  how  tightlv  the  external 
auditory  canal  is  closed,  and  as  a  preliminary  step  to  the  ex- 
amination it  is  essential  that  the  test  sound  emploved  shall 
act  upon  the  organ  under  examination  alone. 

We  begin,  then,  by  placing  the  patient  in  such  a  position 
that  the  ear  to  be  examined  is  turned  toward  the  source  of 
sound  ;  the  opposite  meatus  is  tightly  closed  by  the  finger 
of  the  patient  or,  better  still,  bv  that  of  an  assistant.  To  se- 
cure jx-rfect  occlusion  the  digit  should  be  previously  mois- 
tened with  water.  When  the  hearing  is  im]:)aired  to  a  great 
degree  and  we  have  reason  to  doubt  the  efhciency  of  this 
method  of  excluding  sound  from  the  opposite  ear,  at  the  con- 
clusion of  the  examination  of  the  affected  car,  both  external 
auditory  canals  should  be  closed  and  the  examination  re- 
peated. If  now  the  patient  hears  equally  well  with  both 
canals  closed,  it  is  evident  that  the  affected  ear  exerted  no  in- 
fluence upon  the  results  obtained  by  the  first  tests — in  other 
words,  that  the  ear  upon  this  side  is  totally  deaf.  If,  how- 
ever, the  results  are  not  the  same,  the  hearing  power  upon 
the  affected  side  is  obtained  by  subtracting  the  perception 
distance  obtained  by  the  last  experiment  from  that  elicited  by 
the  first. 

It  is  possible,  under  certain  conditions,  to  convey  the  sono- 
rous vibrations  to  the  affected  ear  through  a  tube,  the  sound- 
ing body  being  removed  to  a  distance  sufficient  to  prevent 
perception  by  the  organ  of  the  opposite  side.  This  is  par- 
ticularly valuable  if  the  method  is  adopted  of  estimating  the 

*  Archiv  fiir  Ohrenheilkunde,  vol.  xii,  p.  282. 


148 


FUNCTIONAL    EXAMINATION. 


hearing  power  by  comparing  interval  during  which  the  sound 
is  perceived,  with  that  of  the  normal  ear. 

II.  Qualitative  Tests. — We  recall  that  the  normal  ear  per- 
ceives vibrations  as  musical  notes  repeated  at  regular  intervals 
from  i6  V.  S.  to  about  32,500  V,  S.  These, 
then,  may  be  called  the  lower  and  upper 
limits  of  auditi(Mi,  respectivelv.  When  the 
organ  is  functionally  perfect  these  limits 
vary  but  slightly.  When,  however,  either 
the  perceptive  or  transmitting  mechanism  is 
the  seat  of  a  pathological  process,  these  lim- 
its are  changed  in  a  characteristic  manner. 

To  complete  our  functional  examination, 
then,  it  is  essential  to  be  provided  with  some 
convenient  device  for  producing  the  lower 
notes  of  the  musical  register — tliat  is,  from 
16  to  20  V.  S.  to  64  V.  S.  per  second — and 
also  some  instrument  which  will  emit  the 
shiill,  high-pitched  sound,  caused  bv  im- 
jiulses  following  each  other  with  extreme 
rapiditv.  The  first  requisite  is  easilv  ob- 
tained through  the  medium  of  a  tuning  fork 
of  large  size.  If  provided  with  clamps,  n 
single  instrument  mav,  bv  altering  the  posi- 
tion of  these,  be  made  to  vibrate  at  varying 
rates.  The  fork  shown  in  Fig.  61  answers 
this  purpose  fairly  well.  When  the  clamps 
are  fastened  at  the  extremity  of  the  branches 
of  the  fork  the  instrument  makes  about  26 
V.  S.  When  a  little  care  is  exercised  in  set- 
ting the  fork  in  vibration,  this  note  is  prac- 
tically pure  and  is  easilv  perceived  as  a  mu- 
sical sound.  When  the  clamps  are  moved 
down,  so  that  about  half  the  length  of  each 
for  determining  tiie  clamp  cxtcuds  bcyond  the  free  extremity  of 
The  instrument  is  the  arm  of  the  fork,  as  shown  bv  the  dotted 
provided  with  ad-     lines  in  Fig.  6i,  the  rate  of  vibration  increases 

iustable  clamps.  '  ,1,-,  •     1 

to  about  thirtv  per  second.  W  hen  carried 
still  lower,  the  note  corresponds  verv  nearlv  to  the  contra  C 
of  the  musical  scale.  If  the  clamp  is  entirelv  removed  the  fork 
emits  a  pure  note  corresp(~)nding  to  the  next  octave  higher; 
in  other  words,  it  makes  sixty-four  vibrations  per  second. 


I' 

I 


Fig.    61.  — Th 
thor's   tun i no 


au- 
fork 


QUALITATIVE    TESTS.  149 

While  this  device  does  not  by  any  means  allow  us  to  ex- 
amine the  lower  portion  of  the  scale  as  thorojighlv  as  we  ma}' 
desire,  it  reveals  very  quickly  any  deticiency  in  audition  for 
the  lower  notes  of  the  scale. 

The  Galton  whistle  affords  a  simple  means  of  producing^ 
the  higher  notes  of  the  musical  scale,  for  determining  the  up- 
per tone  limit.  This  apparatus  is  essentially  a  closed  organ 
pipe  in  which  the  column  of  air  is  set  in  vibration,  either 
through  the  medium  of  the  expired  air,  bv  holding  it  between 
the  lips,  or,  better  still,  by  means  of  a  rubber  ball  fitted  to 
its  open  extremity.  By  a  well-known  law  of  physics,  if  the 
diameter  of  a  tube  is  uniform,  the  note  produced  bv  forcing 
air  through  it  will  become  higher  and  higher  as  the  length  of 
the  tube  diminishes.  Thus,  if  the  length  is  diminished  one 
half,  the  resulting  note  will  be  an  octave  higher  than  the  funda- 
mental ione  of  the  original  tube,  and  bv  decreasing  the  length 
of  the  tube  gradually,  all  of  the  various  musical  notes  mav 
be  obtained  between  the  fundamental  tone  of  the  tube  and 
that  emitted  bv  a  pipe  of  infinitesimal  length. 

The  length  of  the  tube  is  reduced  by  a  metal  obturator, 
which  is  slowly  advanced  along  its  lumen  through  the  agency 
of  a  screw  ;  the  outer  surface  of  the  tube  is  graduated,  each 
division  of  the  vertical  scale  representing  the  space  traversed 
by  the  obturator  during  a  single  complete  rotation  of  the 
screw. 

Owing  to  the  fact  that  so  manv  of  the  instruments  sold 
are  not  made  according  to  a  fixed  rule,  the  graduations  of  the 
scale  can  not  be  employed  in  comparing  the  results  obtained 
by  examination  with  different  instruments.  It  has  seemed 
wise,  therefore,  to  state  here  bricflv  the  means  by  which  the 
number  of  vibrations  per  second  which  any  instrument  of  this 
kind  produces  mav  be  determined. 

The  Galton  whistle  acts  as  a  closed  organ  pipe,  and  the 
variation  in  j)itch  of  the  notes  produced  depend  upon  the  phys- 
ical rules  which  govern  the  construction  of  wind  instruments 
of  this  class.  By  the  law  of  closed  tubes  the  length  of  the 
tube  producing  a  given  note  is  one  quarter  the  wave  length. 
Without  going  into  detail,  it  will  be  sufficient  to  state  that  in 
any  instrument  of  this  character  the  number  of  vibrations  per 
second  may  be  calculated  by  dividing  the  velocity  with  which 
sound  travels  bv  four  times  the  length  of  the  closed  tube. 
Sound  travels  through  the  air,  at  the  average  temperature,  at 


150  FUNCTIONAL   EXAMINATION. 

the  rate  of  eleven  hundred  and  eighteen  feet  per  second  ;  this 
number,  divided  by  four  times  the  length  of  the  tube  which 
produces  the  note  in  question,  will  give  the  rate  of  vibration. 
In  other  words,  the  result  obtained  by  dividing  eleven  hun- 
dred and  eighteen  feet  by  the  length  of  the  tube,  is  equal  to 
four  times  the  number  of  vibrations  producing  the  funda- 
mental note  of  the  tube. 

A  more  exact  method  of  determining  the  upper  tone  limit 
is  by  means  of  a  series  of  rods,  known  as  Koenig's  rods. 
These  small  steel  cvHnders  are  of  various  lengths,  the  diam- 
eter of  each  being  the  same.  To  elicit  the  primary  note  of 
one  of  these  rods  it  is  suspended  bv  means  of  loops  of  very 
light  wire  or  of  silk  thread,  from  points  equidistant  from  the 
two  extremities  of  the  cylinder,  the  location  of  the  points 
of  support  being  determined  by  certain  mathematical  laws. 
These  cylinders  are  set  in  vibration  by  a  small  metallic  ham- 
mer and  emit  a  pure  tone,  the  pitch  of  which  varies  with  the 
length  of  the  cylinder.  This  method  of  determining  the 
upper  tone  limit  is  probably  more  exact  than  that  in  which 
the  Galton  whistle  is  used,  but  it  is  much  more  tedious,  and 
for  clinical  purposes  yields  scarcely  better  results. 

By  the  low-pitch  tuning  fork  and  the  Galton  whistle  we 
may  determine  the  limits  between  which  musical  notes  are 
perceived.  Bczold  *  advises  a  more  exhaustive  investigation, 
and  has  devised  a  series  of  forks  and  organ  pipes  bv  which 
the  complete  series  of  musical  notes  between  the  limits  of 
audition  can  be  produced.  As  the  employment  of  such  a 
number  of  instruments  in  examining  each  case  involves  the 
expenditure  of  considerable  time,  their  use  must  be  confined 
to  the  investigation  of  particular  cases,  in  which  so  exhaustive 
a  test  seems  necessary. 

The  value,  as  a  diagnostic  measure,  of  the  next  test  to  be 
applied  depends  upon  the  fact  that,  under  normal  conditions, 
sound  waves  impress  the  perceptive  centres  by  the  transmis- 
sion of  the  sonorous  impulses  to  the  labyrinth  through  the 
medium  of  the  conducting  mechanism — that  is,  through  the 
external  auditory  meatus,  the  tympanic  membrane,  and  the 
ossicular  chain.  As  a  matter  of  habit,  all  sounds  are  best 
perceived  through  this  avenue,  under  normal  conditions.  If, 
however,  the  conducting  mechanism  is  obstructed,  be  the  ob- 


^Arch.  fiir  Ohrenheilk.,  vol.  xxx,  p.  283. 


BONE    CONDUCTION— WEBER'S    TEST,  151 

struction  in  the  canal,  in  the  tympanic  membrane,  or  within 
the  middle  ear  itself,  this  path  along  which  the  sound  waves 
normally  pass  is  closed  to  a  greater  or  less  degree,  depending 
upon  the  completeness  of  the  obstruction.  Under  these  con- 
ditions, the  vibrations  must  reach  the  end  organ  of  the  audi- 
tory nerve  by  some  other  path,  as,  for  example,  the  solid 
structures  of  the  cranium ;  and  under  these  conditions  a  vi- 
brating body  held  in  contact  with  the  cranial  bones  produces 
a  greater  impression  upon  the  auditory  centres — that  is,  is 
heard  more  loudly — than  when  held  in  front  of  the  external 
auditory  meatus.  It  is  to  be  remembered  that  under  normal 
conditions  also,  when  a  sounding  body  is  brought  into  con- 
tact with  the  bones  of  the  skull,  the  vibrations  arc  perceived. 
The  period  during  which  the  sound  is  heard,  however,  is 
much  less  than  the  interval  during  which  it  is  perceived 
when  held  before  the  auditorv  canal.  Roughlv  speaking,  the 
duration  of  air  conductitni  is  about  double  that  of  bone  con- 
duction, the  air  conduction  being  relatively  somewhat  greater 
for  the  higher  notes — that  is,  a  little  more  than  twice  that  of 
bone  conduction — and  the  bone  conduction,  on  the  other 
hand,  slightly  greater  for  the  lower  notes  of  the  scale,  or  a 
little  more  than  half  that  of  air  conduction.  Again,  the  very 
highest  notes  are  scarcelv  heard  bv  bone  conduction  under 
normal  conditions,  while  the  very  low  notes  of  the  register 
are  felt  rather  than  heard,  when  the  instrument  producing 
them  is  brought  in  contact  with  the  head.  Age  also  influ- 
ences the  power  of  bone  conduction,  which  becoiucs  much 
reduced  after  the  age  of  forty-five  or  fifty  years. 

Having  learned  the  history  of  the  malady,  and  determined 
the  physical  condition  of  the  ear  in  the  manner  i>revi(jusly 
detailed,  and  having  arrived  at  a  conclusion  concerning  the 
extent  of  impairment  by  the  functional  examination,  the  next 
step  should  be  to  locate  the  pathological  condition  either 
in  the  sound-conducting  or  the  sound-perceiving  apparatus. 
Many  of  the  methods  employed  for  this  purpose  bear  the 
names  of  the  investigators  who  first  demonstrated  their  value. 
The  test  most  commonly  spoken  of  is  that  of  Weber,  who,  as 
the  result  of  a  series  of  investigations,  found  that  when  a  vi- 
brating tuning  fork  w^as  placed  upon  the  skull  in  the  antero- 
posterior vertical  median  plane  and  the  meatus  of  one  side 
was  closed,  the  sound  of  the  fork  was  heard  more  strongly  in 
the  ear  which  was  occluded.     In  the  same  way  if  the  struc- 


152 


FUNCTIONAL    EXAMINATION. 


tures  of  the  middle  ear  were  bound  down  by  adhesions,  if  the 
cavity  was  filled  with  fluid,  or  if  the  ligamentous  tissues  were 
so  relaxed  that  the  weight  of  the  drum  membrane  and  the 
attached  ossicular  chain  constituted  an  obstruction  to  the 
passage  of  sonorous  vibrations  from  the  external  canal  to  the 
parts  beyond — under  all  of  these  conditions  the  vibrating  tun- 
ing fork  was  heard  better  in  the  obstructed  ear.  The  deduc- 
tion was  inevitable  that,  in  a  case  in  which  impairment  of 
hearing  existed  upon  one  side  alone,  or  in  which  impairment 
existed  on  both  sides  to  an  unequal  degree,  the  perception  of 
the  tuning  fork  from  the  median  line  of  the  head  would  be 
stronger  in  the  ear  in  which  the  pathological  condition  in  the 
conducting  mechanism  was  more  marked.  In  other  words, 
the  fork  would  be  better  perceived  by  bone  conduction  in  the 
poorer  ear.  If  the  organ  upon  one  side  was  normal,  the  fact 
of  the  fork  being  heard  better  in  this  car  would  locate  the 
pathological  condition  of  the  opposite  side  in  the  perceptive 
rather  than  in  the  transmitting  apparatus. 

The  second  classical  test  was  devised  by  Rinne,*  who  was 
the  first  to  determine  that  the  normal  ear  perceived  a  vibrat- 
ing tuning  fork,  held  before  the  canal,  for  about  twice  as  long 
a  time  as  when  the  shank  of  the  fork  rested  upon  the  mastoid 
process.  In  cases  where  the  canal  was  occluded,  or  where  an 
obstructive  lesion  was  present  within  the  tympanum,  it  was 
found,  after  the  fork  had  ceased  to  be  heard  in  front  of  the 
ear,  that  its  vibrations  could  still  be  recognized  when  the 
handle  of  the  instrument  was  bnought  in  contact  with  the 
mastoid.  In  applying  this  method  of  investigation  then,  if,  in 
a  given  case  in  which  the  hearing  is  impaired,  the  duration  of 
bone  conduction  is  greater  than  that  of  air  conduction,  the  in- 
ference would  be  that  the  im])airmcnt  is  due  to  some  lesion 
of  the  conducting  apparatus,  and,  pathological  conditions  of 
the  canal  being  excluded  bv  phvsical  examination,  the  loca- 
tion of  the  morbid  process  must  of  necessitv  be  the  tvmpanic 
structures.  If,  on  the  other  hand,  the  hearing  is  impaired 
and  the  normal  relation  between  bone  and  air  conduction  is 
preserved,  although  both  are  found  to  be  reduced,  the  seat 
of  the  disease  must  be  the  perceptive  portion  of  the  organ  of 
hearing. 

While   both   of  these   facts  are   of   undoubted   value,  the 

*  Prager  Viertcljahresschrift,  1S55,  vol.  i,  p.  71,  vol.  ii,  pp.  45-155. 


RINNE'S   TEST.  1 53 

accumulation  of  clinical  evidence  from  the  investigation  of  a 
large  number  of  cases,  has  convinced  those  interested  in  Otol- 
ogy that  in  many  instances  they  can  not  rely  absolutely  upon 
these  reactions  to  indicate  the  site  of  the  lesion. 

The  first  fact  with  which  we  are  impressed  in  a  careful 
reading  of  these  experiments  is  that  very  little  attention  seems 
to  have  been  paid  to  the  pitch  of  the  fork  used  in  conducting 
the  tests.  From  what  we  know  bv  experiment  (see  Physi- 
ology) of  the  effects  of  increase  of  tension  in  the  iiitratvmpanic 
structures,  or  the  weighting  of  these  parts  or  of  tiie  tvmpanic 
membrane,  it  can  easily  be  seen  that  if  the  impairment  of 
hearing  is  very  slight  and  the  fork  used  in  making  the  test  is 
of  moderately  high  pitch,  an  absolute  reversal  of  the  relation 
between  the  bone  and  air  conduction  mav  not  take  place, 
since  the  api)lication  of  a  load  to  the  drum  mcinbiane  or 
ossicles  interteres  principallv  with  their  vibration  in  their  re- 
sponse to  the  lower  notes  of  the  scale.  This  fact  is  recog- 
nized bv  Lucic  and  by  Bczold,*  the  latter  restricting  the  aj)- 
plicability  of  Rinne's  exj)eriment  to  those  cases  in  which  the 
whispered  voice  is  not  understood  at  a  distance  greater  than 
three  and  a  half  feet.  It  must  be  remembered,  that  in  arriv- 
ing at  this  conclusion  regarding  the  aj)j)licati()n  of  Rinne's 
test,  a  tuning  fork  making  about  512  V.  S.  was  used,  liy  the 
use  of  forks  of  lower  pitch  the  test  bcc(Miies  applicable  to  cases 
in  which  the  degree  of  impairment  is  much  less  than  this. 
It  is  seldom  wise,  however,  to  determine  bone  conduction 
with  a  fork  of  lower  pitch  than  128  V.  S.,  since  a  fork  lower 
than  this  is  felt  rather  than  heard,  and  comparatively  few 
patients  are  able  to  distinguish  between  the  two  sensations. 
If  a  fork  making  512  V.  S.  is  used  in  cases  where  the  impair- 
ment is  slight,  instead  of  looking  for  an  al)solute  reversal  of 
the  relation  between  bone  and  air  conduction,  a  com[)arison 
should  be  made  between  the  time  during  which  the  fork  is 
heard  when  held  in  front  of  the  canal  and  that  during  which 
it  is  perceived  when  placed  uf)on  the  mastoid.  It  will  be 
found  that  bone  conduction  is  increased  relatively,  although 
Rinne's  test  will  be  positive.  Sucii  a  result  is  called  "  a  di- 
minished positive."  For  clinical  purposes,  however,  it  would 
be  impossible  to  conduct  the  test  in  this  manner,  as  the  dura- 
tion periods  would  then  need  to  be  determined  with  great 

*  AUg.  Wien.  med.  Ztg.,  1887,  p.  183. 


154 


FUNCTIONAL   EXAMINATION. 


exactness,  and  reliable  results  could  be  obtained  only  by 
complicated  apparatus. 

Following  in  this  same  line,  Schwabach  *  has  found  that 
where  obstruction  exists  in  the  conducting  mechanism,  the 
absolute  period  of  bone  conduction  exceeds  that  of  the 
normal  ear.  Pomcroy.f  in  applying  this  test  insists  upon  the 
ears  being  tightly  stopped  with  the  fingers.  In  other  words, 
he  compares  the  maximum  bone  conduction  to  be  obtained 
from  the  normal  ear  with  that  to  be  elicited  from  the  organ 
under  examination,  combining  really  the  test  of  Schwabach 
with  that  of  Weber. 

The  determination  of  the  absolute  bone  conduction  in  sec- 
onds, not  only  consumes  considerable  time,  but  the  result 
obtained  must  vary  with  the  age  of  the  patient,  and  with  dif- 
ferent examiners.  The  variations  in  the  force  of  the  blow 
setting  the  fork  in  vibration  also  constitute  a  source  of  error. 
It  is  much  simpler,  if  the  examiner  possesses  a  normal  ear,  to 
follow  the  plan  suggested  by  Gardiner  Brown.:}:  who  con- 
ducts the  test  as  follows:  The  tuning  fork  is  set  in  vibration, 
and  the  handle  is  held  against  the  mastoid  of  the  patient 
until  the  sound  is  no  longer  heard,  this  fact  being  communi- 
cated to  the  examiner  by  the  {Kiticnt  raising  his  hand.  The 
handle  of  the  fork  is  then  applied  to  the  mastoid  of  the  ex- 
aminer, and  if  he  perceives  the  sound,  it  is  fair  to  assume  that 
the  bone  conduction  of  the  patient  is  below  the  iK^rmal  stand- 
ard. If,  on  the  contrary,  he  no  longers  hears  it,  the  inference 
is  that  the  bone  conduction  is  normal.  For  general  purposes, 
the  data  obtained  in  this  manner  are  sufficientlv  exact,  when 
taken  in  connection  with  results  arrived  at  by  applying  the 
other  tests  for  determining  the  location  of  the  lesion. 

Reviewing  briefly  the  facts  stated  in  the  preceding  pages, 
it  will  be  seen  that  lesions  of  the  conducting  mechanism  are 
characterized  by — 

I.  A  loss  or  impairment  of  audition  for  the  lower  notes 
of  the  scale,  and  as  the  degree  of  impairment  of  hearing  in- 
creases, the  lowest  note  which  can  be  perceived,  or  the  lower 
tone  limit,  as  it  is  called,  becomes  elevated. 

II.  The  relative  duration  of  bone  conduction  as  compared 

*  Zeitschrift  fur  Ohrenheilkunde,  vol.  xiv. 

f  Diseases  of  the  Ear,  New  York,  1883,  p.  337. 

X  Lennox  Browne,  The  Throat  and  its  Diseases,  London,  1SS7,  p.  535. 


DIFFERENTIAL    DIAGNOSIS.  155 

with  air  conduction  increases,  the  inversion  of  the  ratio  being 
more  marked  for  the  lower  notes  of  the  scale  and  affecting 
these  first,  the  change  occurring  with  the  higher  notes  in 
proportion  as  the  pathological  condition  increases,  and  conse- 
quently as  the  impairment  of  function  becomes  more  marked. 

III.  Lesions  of  the  conducting  apparatus  interfere  very 
slightly  with  the  perception  of  the  highest  notes  of  the  scale 
by  air  conduction — in  other  words,  have  very  little  effect  upon 
the  upper  tone  limit. 

In  the  same  manner  diseases  of  the  receptive  mechanism 
are  characterized  by — 

I.  No  elevation  of  the  lower  tone  limit. 

II.  No  change  in  the  normal  relation  between  the  duration 
of  bone  conduction  as  ci)mpared  with  air  conduction,  the 
absolute  duration  of  both,  however,  being  reduced. 

III.  Abscjlutc  deafness  for  certain  notes  of  the  scale, 
usually  in  its  uj)per  portion,  thus  frequently  lowering  the 
upper  tone  limit.  This  is  almost  invariably  the  case  when 
the  conditic^n  is  sccondarv  to  changes  within  the  tvmpanum. 

Our  plan  of  functitjnal  examination,  then,  is  essentially  as 
follows : 

The  cjuautitativc  dctcrutitiation  of  tlic  luarmg  by  vwans  of : 

a.  The  watch,  if  the  impairment  is  slight. 

/;.  The  acoumeter,  if  the  degree  of  impairment  is  more 
marked. 

c.  The  determination  of  the  hearing  distance  by  means  of 
the  "forced  whisper"  by  making  use  of  numbers  of  two 
figures. 

The  qualitative  deteruiination  of  the  hearing : 

a.  The  determination  of  the  lower  tone  limit,  using  for 
this  purpose  the  fork  already  described,  illustrated  in  Fig.  61. 
The  record  shows  the  lowest  number  of  vibrations  perceived 
by  the  patient  as  a  musical  note,  the  different  rates  of  oscilla- 
tion being  obtained  bv  changing  the  position  of  the  clamps 
as  alreadv  explained. 

h.  The  determination  of  the  upper  tone  limit  by  means 
of  the  Galton  whistle,  recording  the  highest  number  of  vibra- 
tions perceived  bv  the  patient  as  a  musical  sound. 

c.  The  determination  of  absolute  bone  conduction. 

In  determining  the  absolute  bone  conduction  in  any  given 
case  the  rate  of  vibration  of  the  tuning  fork,  as  has  already 
been  stated,  must  be  taken  into  account.     In  patients  under 


156 


FUNCTIONAL   EXAMINATION. 


forty  years  of  age  the  most  convenient  fork  to  be  employed 
is  one  tuned  to  the  note  "  C,"  making  five  hundred  and  twelve 
double  vibrations  per  second.  In  patients  over  forty,  a  fork 
making  two  hundred  and  filty-six  double  vibrations  per  second 
gives  the  most  accurate  results.  For  the  benefit  of  those  who 
do  not  care  to  make,  a  special  study  of  aural  diseases,  and 
hence  to  whom  a  multiplicity  of  devices  for  determining  the 
actual  functional  condition  of  the  ear  is  rather  objectionable, 
it  may  be  well  to  enumerate  the  instruments  with  which  satis- 
factory work  can  be  done. 

In  the  first  place,  it  is  necessary  to  be  provided  with  a  low- 
pitched  tuning  fork,  such  as  the  one  shown  in  Fig.  6i,  fitted 
with  clamps,  by  means  of  which  the  rate  of  vibration  can  be 
changed  by  altering  their  position  upon  the  limbs  of  the  fork. 
The  highest  note  obtainable  with  this  instrument  is  one  of 
sixtv-four  vibrations  jicr  second.  This  instrument  will  enable 
the  observer  to  determine  defects  in  the  transmission  of  the 
lower  notes  of  the  scale,  a  condition  which  is  characteristic  of 
the  lesions  of  the  conducting  apparatus.  It  niav  not  be  possi- 
ble for  him  to  determine  the  lower  tone  limit,  as  it  may  lie 
above  the  highest  note  obtainable  with  this  fork;  but  if  the 
lower  tone  limit  lies  above  64  V.  S.,  the  inference  must  be 
that  the  sound-conducting  apparatus  is  not  in  a  normal  con- 
dition. For  the  determination  of  the  upper  tone  limit  the 
observer  must  be  provided  with  a  Galton  whistle.  The  modi- 
fied form,  devised  by  the  author  and  shown  in  Fig.  62,  gives 
a  greater  range  than  the  original  instrument  of  Galton,  and  is 


I'"lG.  62. — The  auilior's  moiiinc.TUon  ol  ih 
Gallon  whistle. 


preferable  when  onlv  a  limited  number  of  tuning  forks  are 
at  hand.  This  whistle  enables  tests  to  be  made  through  a 
compass  of  from  about  sixteen  hundred  and  seventy-seven  vi- 
brations per  second  to  about  forty  thousand  vibrations  per 
second,  the  increased  length  of  the  instrument  augmenting 
the  compass  ;  it  thus  supplies  the  place  of  the  higher  tuning 
forks. 

For  the  determination  of  bone  conduction,  if  but  one  in- 
strument is  to  be  used,  the  C  fork,  making  512  V.  S.,  is  the 


INSTRUMENTS. 


n 


\) 


best  for  general  use,  since  its  construction  is  comparatively 
simple,  and  overtones  interfere  but  little  with  its  primary 
note.  The  instrument  (Fig.  63)  devised  by  Blake,  and  mak- 
ing 256  V.  S.,  is  also  exceedingly  well  adapted  to  this  pur- 
pose. In  this  fork  the  overtones  are  avoided  by  increasing 
the  weight  of  the  branches  at  their  free  ex- 
tremities. With  these  three  instruments  a 
fairly  accurate  functional  examination  can 
be  made,  and  the  deductions  drawn  from 
the  data  thus  obtained  will  scarcely  ever  be 
misleading.  A  more  extended  examination 
w  ill  simply  confirm,  in  .most  instances,  the 
opinicMi  already  lormed  as  the  result  of  the 
investigation  with  the  above  limited  num. 
ber  of  instruments.  It  is  of  advantage,  of 
course,  to  have  appliances  at  hand  for  the 
producticjn  of  all  the  ncjtes  of  the  musical 
scale,  antl  BczoKl  -  has  ck\ised  a  scries  of 
tuning  forks  and  oi  wiiul  instruments  which 
produce  musical  notes  on  the  principle  (»f 
a  closed  organ  pipe,  and  by  whicli  the  in- 
vestigator can  obtain  any  note  of  the  scale 
between  the  high  and  low  limits  of  audition. 
The  series  consists  of  eight  tuning  forks, 
two  organ  pipes,  and  one  Gallon  whistle. 
Hven  lor  a  very  exhaustive  investigation 
of  any  case  it  is  scarcely  necessary  to  multiply  the  arma- 
mentarium to  this  extent,  since  by  means  of  the  low  fork 
already  mentioned,  together  with  the  modified  Galton  whistle 
and  the  series  of  five  forks  recommended  by  Ilartmann  f  (I'ig. 
64),  perfectly  satisfactory  work  can  be  done. 

Each  of  the  five  forks  in  this  set  is  tuned  to  the  note  C ; 
the  lowest  fork  making  one  hundred  and  twenty-eight  vibra- 
tions per  second,  while  the  highest  registers  two  thousand 
and  forty-eight  vibrations  per  second,  each  fork  being  tuned 
an  octave  higher  than  the  one  below  it.  This  particular  range 
is  chosen  as  it  includes  those  fundamental  notes  which  may 
be  called  essential  to  perfect  audition — that  is,  the  range  of 
notes  employed  in  ordinary  conversation.     In  addition,  the 


Fig.  63. — Blake's  tun- 
ing fork.  The  rate 
of  vibration  indi- 
cated on  the  handle 
(512)  refers  to  single 
vibrations. 


*  .Vrchiv  fiir  Ohrenheilk.,  vol.  xxx,  p.  283. 
t  Krank.  des  Ohres,  Berlin,  1889,  p.  32. 


1^8 


FUNXTIONAL   EXAMINATION. 


8 


Gallon  whistle  will  enable  an  investigation  as  to  the  power 
of  the  patient  to  perceive  those  notes  of  the  scale  lying  above 

the  highest  fork  of  the 
Hartmann  series.  I  have 
employed  these  instru- 
ments for  some  time,  and 
have  seldom  been  misled 
in  the  deductions  made 
from  the  results  thus  ob- 
tained. 

In  making  these  quali- 
tative tests  certain  pre- 
cautionary measures  are 
necessary  :  for  example, 
to  avoid  the  production 
of  overtones  in  using  the 


J 


fci 


II 


Fig.  64. — Ilartinann's  series  of  tuning  forks. 


large  tuning  fork  with 
the  clamps  so  placed  as 
to  produce  the  lowest 
obtainable  rate  of  vibra- 
tion— that  is,  twenty-six  vibrations  per  second.  It  care  is 
not  taken,  an  overtone  will  be  produced  when  the  fork  is 
struck,  and  this  may  be  perceived  by  the  patient  to  the  ex- 
clusion of  the  very  low  primary  note  of  the  fork.  In  every 
instance,  therefore,  the  observer  should  make  certain  by  hold- 
inof  the  vibratinir  fork  for  a  moment  before  his  own  ear  be- 
fore  it  is  used  to  test  the  patient,  that  the  primary  note  alone 
is  elicited.  It  must  also  be  remembered  in  testing  air  con- 
duction with  tuning  forks,  that  the  fork  may  be  held  in  front 
of  the  ear  in  such  position,  that  its  note  will  not  be  perceived, 
on  account  of  the  interference  of  the  sound  waves,  which 
completely  neutralize  each  other  and  cause  absolute  silence. 
This  phenomenon  depends  entirelv  upon  certain  physical 
facts,  as  pointed  out  long  ago  by  Weber.*  That  this  inter- 
ference may  take  place  the  fork  is  held  so  that  cither  of  the 
four  angles  of  the  parallelogram  inclosed  by  the  branches 
is  directed  toward  the  meatus.  During  the  complete  rota- 
tion of  the  fork  upon  its  long  axis,  therefore,  there  will  be 
four  periods  during  which  the  note  is  heard,  alternating  with 
four  periods  of  complete  silence.     It  is  hardly  necessary  to 


*  Die  Wellenlehre,  Leipzig,  1825,  p.  506. 


PRECAUTIONARY    MEASURES.  1 59 

say,  in  conducting  the  functional  examination,  that  care  must 
in  any  case  be  exercised  that  each  of  these  positions  is  avoided. 
Urbantschitsch  *  has  also  demonstrated  that  when  the  vibrat- 
ing fork  is  carried  toward  the  ear  from  before  backward  it  is 
not  heard  as  it  passes  the  anterior  and  posterior  margins  of 
the  meatus,  and  the  same  phenomenon  is  observed  as  it  passes 
the  superior  and  inferior  boundaries  of  the  meatus,  if  carried 
from  above  downward. 

In  testing  absolute  bone  conduction  it  often  happens  that 
the  patient  confuses  the  feeling  of  vibration  communicated  by 
the  instrument  to  the  cranial  bones  with  the  perception  of  the 
tone  which  it  produces.  This  is  particularly  true  when  forks 
of  low  pitch  are  employed  in  making  tests,  and  in  cases  of  al- 
most absolute  dcatncss.  The  first  error  can  be  avoided  bv 
using  a  fc^rk  of  higher  jiitch,  the  second  bv  bringing  the  vibrat- 
ing fork  in  contact  with  some  other  portion  of  the  body,  as, 
for  instance,  by  pressing  the  handle  uj)on  the  elbow  or  knee, 
and  questioning  the  patient  as  to  whether  the  sensation  is  ex- 
actly the  same  as  when  the  instrument  is  applied  to  different 
parts  of  the  cranium.  If  it  is,  it  naturally  f(jllows  that  he  has 
confused  the  tactile  sensibility  with  the  auditory  sense,  and 
his  statements  are  consequentlv  unreliable. 

It  should  also  be  remembered  that  the  feeling  of  vibration 
is  much  more  marked  when  the  handle  of  the  fork  is  slender 
than  when  it  is  of  considerable  thickness,  and  this  should  be 
borne  in  mind  in  selecting  an  instrument  for  testing  bone 
conduction. 

In  using  the  Gallon  whistle  the  instrument  is  held  close 
to  the  entrance  of  the  canal  and  the  current  of  air  is  so  regu- 
lated as  to  produce  the  most  perfect  musical  note  obtainable 
with  the  scale  in  any  given  position.  Here  the  individual 
tested  mav  not  distinguish  between  the  blowing  sound  pro- 
duced by  the  air  and  the  high-pitched  musical  note  which  he 
should  hear.  If  the  length  of  the  tube  is  increased  so  that  a 
distinct  whistle  is  at  first  heard  and  then  graduallv  reduced 
by  advancing  the  obturator  by  turning  the  screw,  thus  pro- 
ducing notes  successively  higher  in  pitch,  he  will  easily  dis- 
tinguish the  point  at  which  the  whistling  sound  disappears 
and  the  blowing  or  puffing  sound  is  heard.  If  the  screw  is 
then    turned    in    the    opposite  direction    until    the   whistling 

*  Lehrb.  der  Ohrenheilk.,  Vienna,  1890,  p.  37. 


l6o  FUNCTIONAL    EXAMINATION. 

sound  is  again  perceived,  a  reading  of  the  scale  will  give  the 
true  uj)per  tone  limit.  Further,  the  patient  should  be  made 
to  describe  the  character  of  the  sound  in  his  own  words  and 
without  any  suggestion  on  the  part  of  the  surgeon,  as  the 
latter  can  easily  infer  from  the  reply,  whether  the  impression 
is  that  of  a  musical  note  or  simply  the  blowing  due  to  the 
current  of  air. 

It  would  seem,  therefore,  a  matter  of  no  great  difficulty  to 
make  a  fairly  accurate  differentiation  between  diseases  of  the 
sound-conducting  and  sound  perceiving-apparatus.  We  meet 
with  a  large  class  of  cases,  however,  in  which  both  portions 
of  the  auditory  organ  are  at  fault,  the  perceptive  aj^paratus 
being  secondarily  affected  as  the  result  of  pathological  condi- 
tions in  the  sound-conducting  mechanism.  Here,  then,  the 
results  obtained  by  the  above  tests  may  be  confusing.  In 
order,  therefore,  to  interpret  correctly  the  data  obtained  from 
such  an  examination,  it  is  necessary  to  inquire  somewhat 
closely  into  the  causes  which  are  operative  in  the  production 
of  the  phenomena  ahead v  described. 

It  is  conceded  that  the  augmentation  of  bone  conduction 
in  pathological  conditions  of  the  meatus  and  middle  ear  which 
cause  an  obstruction  to  the  j)assage  of  sonorous  waves  inward, 
is  due  to  the  fact  that  it  prevents  the  passage  of  undulations  out- 
ward from  the  ear  when  the  vibrating  bodv  is  brougiit  in  con- 
tact with  the  cranial  bones  in  the  same  manner  as  it  offers  a 
barrier  to  their  propagation  in  the  opposite  direction  when  the 
source  of  sound  is  held  near  the  meatus.  Stcinbruegge  *  con- 
siders that  the  absolute  or  relative  increase  in  the  bone  con- 
duction in  these  cases  is  due  to  a  condition  of  hvpcra?sthesia 
of  the  auditory  nerve  resulting  from  the  mechanical  irritation 
to  which  its  terminal  fibres  are  subjected.  While  this  condi- 
tion of  increased  irritability  may  be  present  in  many  cases,  it 
is  certainly  not  the  cause  of  the  increased  bone  conduction 
in  most  instances,  other  symptoms  of  auditory  hvpersensitive- 
ness  being  wanting  in  many  cases.  Further,  an  examination 
of  the  condition  of  the  auditory  nerve  by  means  of  the  gal- 
vanic current  fails  to  support  Steinbrucgge's  hypothesis. 

Gradenigof  has  shown  that  lesions  of  the  conducting  ap- 
paratus do  in  some  instances  cause  the  auditor}-  nerve  to  re- 

*  Archives  of  Otolojry,  vol.  xvii,  p.  117. 
f  Arch,  fiir  Ohrenheilk.,  vol.  xxvii,  p.  i. 


IRRKC.l'LAR    PHENOMENA.  l6l 

spond  more  easily  to  the  i^ahanic  current  than  under  normal 
conditions;  and  this  fact  should  be  remembered,  as  it  enables 
us  to  interpret  results,  which  would  otherwise  seem  contra- 
dictory, obtained  by  functi(jnal  examinations  in  certain  cases. 

The  experiments  of  Siebenmann  *  demonstrate  that  an 
increase  in  the  labyrinthine  j^ressure  prolongs  bone  conduc- 
tion, as  evidenced  bv  an  examination  before  and  after  \'al- 
salva's  inflati(jn  (the  latter  prctccdure.  as  is  well  known,  in- 
creasing the  tension  oi  the  labyrinthine  fluid).  In  cases 
where  the  membrana  tympani  had  been  destroyed  the  laby- 
riuihine  pressure  was  increased  by  j»ressing  the  head  of  the 
stapes  inward  by  means  of  a  ])r()be. 

We  should  expect,  therefore,  to  find  a  jiroloiiLration  oi  the 
interval  during  which  the  tuning  tork  is  heard  when  brought 
in  contact  with  the  cranial  bones,  in  all  cases  where  sjieculum 
examination  shows  either  a  depressed  drum  membrane,  or  the 
presence  of  adhesions  within  the  tympanum,  diauiiig  the 
ossicular  chain  toward  the  inner  tynijianic  wall.  This  is  usu- 
ally the  case,  but  occasionally  we  find  that  the  reverse  is 
true.  The  latter  condition  can  be  explained  ui)on  the  hy- 
pothesis that  the  condition  of  increased  tension  has  lasted  so 
long  that  the  function  of  the  auditory  nerve  has  been,  to  a 
certain  extent,  ablated  by  the  mechanical  pressure,  and  that 
the  case  is  no  longer  one  of  intratymj)anic  disease  pure  and 
simple,  but  that  an  actual  pathological  condition  is  present 
within  the  labyrinth,  depeniient  upon  the  disturbance  within 
the  middle  ear. 

When  the  intratvmpanic  changes  are  cotiiji;iiaiiv(.  ly  sud- 
den, as  in  cases  of  simj)le  congestion  and  a-dema  of  the 
Eustachian  tube  with  displacement  of  the  drum  membrane 
and  of  the  entire  ossicular  chain  inward,  we  observe  that,  in 
addition  to  an  augmentation  of  bone  conduction,  the  upper 
tone  limit  is  usually  c(jnsiderably  hnvered.  This  is  easily 
explainable  when  we  remember  that  the  highest  notes  of  the 
scale  are  perceived  by  the  lowest  portion  of  the  cochlea. 
This  portion  of  the  labyrinth,  lying  as  it  does  in  immediate 
relation  to  the  foot  plate  of  the  stapes  and  the  membrane  of 
the  round  window,  will  be  easily  affected  not  only  by  changes 
in  the  position  of  the  base  of  the  stapes  and  of  the  membrana 
tympani   secondaria,    but    also    by    circulatory    disturbances 

*  Arch,  of  Otol..  vol.  xxii,  p.  i. 


l62  FUNCTIONAL    EXAMINATION. 

within  the  tympanum.  It  is  not  strange,  therefore,  that  the 
very  highest  notes  of  the  scale  should  be  no  longer  heard 
when  any  sudden  change  of  position  takes  place  in  the  ossi- 
cular chain,  or  when  the  tympanic  mucous  membrane  be- 
comes engorged  with  blood,  interfering  with  the  motility  of 
the  ossicles.  If  the  interference  with  the  function  of  the 
cochlea  depends  simply  upon  a  slowly  increasing  pressure, 
the  equilibrium  of  the  labyrinth  is  but  slightly  disturbed, 
owing  to  the  direct  communication  of  both  the  endolvmphic 
and  perilymphic  spaces  with  the  lymph  channels  within  the 
cranial  cavity.  In  such  cases,  therefore,  very  little  disturb- 
ance of  the  upper  tone  limit  is  observed,  although  the  intra- 
tympanic  structures  mav  be  completely  bound  down  by  adhe- 
sions and  drawn  inward  toward  the  external  labyrinthine 
wall.  The  channels  of  communication,  however,  between 
the  labyrinthine  and  intracranial  lymphatic  spaces  are  so 
narrow,  that  any  sudden  increase  of  pressure  causes  a  dis- 
turbance of  equilibrium  in  the  labyrinthine  fluid,  and  hence 
lowers  the  upper  tone  limit.  It  is  wise,  in  view  of  this  inti- 
mate association  between  the  labyrinth  and  the  tympanum, 
to  repeat  the  qualitative  tests  after  a  restoration  of  the  nor- 
mal air  pressure  within  the  tympanum  by  inflation,  to  guard 
against  all  possibility  of  error. 

In  addition  to  the  tests  given  above,  mention  should  be 
made  of  certain  other  methods  of  investigation  which  lie  at 
our  disposal  in  making  a  differential  diagnosis.  Among  the 
most  important  of  these  are  the  following: 

Bifij^'s*  Rxpcriuunt. — This  test,  flrst  described  by  the 
above-named  author,  is  essentially  a  modification  of  Weber's 
experiment.  It  is  conducted  as  follows:  A  vibrating  tuning 
fork  is  applied  either  to  the  forehead  or  vertex  in  the  median 
line,  and  is  held  in  this  position  until  its  note  is  no  longer 
perceived.  If  at  this  moment  the  finger  is  inserted  into  the 
external  auditory  canal  of  either  side,  the  note  of  the  fc^i^k 
will  again  be  heard.  This  second  interval  during  which  the 
fork  is  perceived  is  called  the  period  of  secondary  perception 
for  the  tone.  If  the  conducting  apparatus  is  normal  this  sec- 
ondary perception  interval  is  well  marked  ;  while  if  its  dura- 
tion is  shortened,  the  presence  of  some  obstructive  lesion  of 
the  conductins:  mechanism  may  be  inferred.     If  the  interval 


*  Wien.  med.  Blaiter,  i8gi,  No.  41. 


GELLE'S    TEST.  163 

of  secondary  perception  is  of  normal  duration,  while  at  the 
same  time  there  is  an  interference  with  the  auditory  appara- 
tus, as  evidenced  by  subjective  or  objective  symptoms,  the 
conducting  mechanism  must  be  in  a  normal  condition,  and 
the  seat  of  the  morbid  process  must  lie  within  the  labvrinth  in 
the  auditory  nerve  or  be  due  to  changes  within  the  ccrebi'al 
hemispheres  or  medulla. 

(jil/c's  Test. — Gelle  *  proposes  to  test  the  mobility  of  the 
ossicular  chain,  and  especially  of  the  stapes,  by  compressing 
the  air  in  the  external  auditory  meatus  and  observing  the 
effect  upon  the  perception  of  the  note  of  a  tuning  fork  in  con- 
tact with  the  skull.  If  the  foot  plate  of  the  stapes  is  movable, 
with  each  condensation  of  air  within  the  meatus  the  sound  of 
tlic  fork  becomes  much  diminished  in  intensity  or  may  be  lost, 
reappearing  again  as  the  pressure  is  relieved.  The  condensa- 
tion is  effected  by  means  of  a  small  air  bag  provided  with  a 
flexible  rubber  tube,  the  free  extremity  f)t  which  carries  a 
conical  tip  which  can  be  inserted  air-tight  into  the  canal.  If 
the  labyrinth  is  affected,  either  primarily  or  secondarily,  the 
tone  will  also  be  diminished,  but  tiie  increase  in  pressure  will 
produce  a  sense  of  dizziness  and  sometimes  tinnitus. 

Rohrcr+ considers  this  test  valuable  when  taken  in  con- 
nection with  Rinne's  test.  According  to  his  investigations, 
when  Rinne's  experiment  was  negative  Gell6's  test  yielded  a 
negative  result  in  seventy-three  per  cent  of  the  cases  tested 
and  a  positive  result  in  but  twenty-three  per  cent.  When 
Rinne's  test  was  positive  Gelle's  test  yielded  negati\e  results 
in  twelve  per  cent  and  positive  results  in  eighty-eight  per 
cent  of  the  cases  examined. 

The  patients  selected  in  these  experiments  of  Rohrer's 
were  cases  in  which  the  hearing  was  very  much  impaired — so 
much,  in  fact,  as  to  make  it  more  than  probable  that  a  laby- 
rinthine lesion  co-existed  with  the  pathological  process  within 
the  tympanum.  Rohrer  lavs  particular  stress  upon  the  value 
of  Gelle's  experiment  in  determining  the  secondary  involve- 
ment of  the  labyrinth  following  an  inflammatory  process 
within  the  middle  ear,  in  which  case  Rinne's  test  very  fre- 
quently yields  negative  results;  if  Gelle's  test  gives  negative 
results  as  well,  the  inference  that  the  labyrinth  is  affected  is 


*  Trihune  medical,  Oct.  23,  1881. 

\  Lehrb.  der  Ohrenlieilk.,  Vienna,  1891,  p.  66. 


164  FUNXTIONAL   EXAMINATION. 

fullv  warranted.  In  cases  where  the  hearin^;^  is  very  much 
impaired,  and  Rinne's  test  is  positive,  Gelle's  test  is  also 
usuall}'  positive,  if  the  labyrinth  is  affected. 

Eitclbcrgs  Test. — Another  experiment,  calculated  to  differen- 
tiate between  lesions  of  the  labyrinth  and  those  of  the  middle 
ear,  is  that  of  Eitelberg.*  It  depends  upon  the  principle  that 
a  nerve  continuously  irritated  by  any  one  stimulus  becomes 
fatigued  after  a  certain  time  and  performs  its  function  less 
readily.  It  follows,  therefore,  that  when  the  {perceptive  tract 
is  in  an  abnormal  contlition  this  effect  will  be  produced  more 
readily  than  in  a  state  of  perfect  health.  In  i)erforming  the 
test  a  large  tuning  fork  is  made  to  vibrate  in  front  of  the  ear 
for  a  period  of  fifteen  or  twenty  minutes,  the  instrument  be- 
ing set  in  vibration  repeatedly  by  as  nearly  as  possible  the 
same  initial  force  as  soon  as  its  oscillations  become  weak.  If 
after  the  nerve  has  been  subjected  to  this  continuous  stimulus 
the  perception  interval  has  not  been  much  shortened,  the  re- 
ceptive apparatus  is  assumed  to  be  in  a  normal  conditic^n.  As 
the  value  of  this  test  depends  greatly  upon  the  intelligence 
of  the  patient,  its  application  is  somewhat  limited.  A  much 
simpler  demonstration  of  auditory  fatigue  is  constantly  jjre- 
sented,  in  cases  where  prolonged  testing  with  sounds  which 
are  of  a  similar  character  as,  for  instance,  the  watch,  acoimieter, 
or  the  whisper  yield  results  which  differ  greatly  from  each 
other,  and  the  ability  to  perceive  the  sound  steadily  decreases 
as  the  patient  becomes  fatigued.  We  otten  note  a  similar  con- 
dition of  the  nerve  in  what  may  be  termed  the  j>ersistencc  of 
an  auditory  impression  ;  for  instance,  in  testing  a  patient  with 
the  watch  it  will  often  be  stated  that  the  sound  is  heard  cither 
after  the  watch  has  been  stopped  or  has  been  removed  to  such 
a  distance  that  it  is  impossible  for  the  sound  to  be  heard. 
This  depends  upon  the  fact  that  an  impression  once  made 
upon  the  auditory  centres  is  retained  by  them  for  a  longer 
period  than  normal,  demonstrating  the  fact  that  they  arc  no 
longer  in  a  state  of  health. 

Gradcnigo  s  Test. — Gradenigo  +  finds  in  cases  in  which  the 
acoustic  nerve-trunk  is  afTected  that  it  quickly  loses  its  power 
of  reacting  to  sonorous  stimuli  if  the  quality  of  the  sound 
remains   unchanged.     In   other  words,  the   nerve   is  quickly 


*  Wien.  med.  Presse,  1SS7.  No.  10. 

t  Handbuch  der  Ohrenheilk.    Von  Schwartze,  Leipzig,  1S93,  vol.  ii,  p.  403. 


CIRAUKNICOS    TEST, 


165 


fatigued.  If,  however,  it  is  allowed  to  rest  for  a  short  time, 
it  is  again  able  to  perform  its  function.  The  simplest  method 
of  practicing  this  test  is  by  the  use  of  a  tuning  fork  of  about 
fifteen  hundred  or  two  thousand  vibrations  per  second  as  the 
source  of  sound.  Such  a  fork  is  perceived  from  fifty  to  sev- 
enty seconds  under  normal  conditions.  In  cases  of  torpidity 
of  the  auditory  nerve,  if  this  fork  is  set  in  vibration  and  held 
close  to  the  ear  its  note  ceases  to  be  audible  after  a  much 
shorter  interval.  If  it  is  now  removed  a  short  distance  from 
the  ear,  for  a  few  seconds,  and  again  carried  close  to  the 
meatus,  it  will  be  again  perceived.  This  manoeuvre  mav  be 
repeated  several  times  during  one  period  of  vibration  of  the 
fork.  It  seems  that  the  auditory  nerve  when  in  this  condition 
is  easily  fatigued,  but  after  an  interval  of  rest  it  mav  react 
to  a  weaker  stimulus  than  that  which  failed  to  excite  it  after 
it  had  been  subjected  to  tliat  one  for  a  certain  time. 

Ciradenig(j*  asserts  that  when  the  auditorv  nerve  trunk  is 
involved  the  interference  with  function  is  particularlv  maiktd 
for  the  tones  of  the  middle  j)ortion  of  the  scale,  the  verv  high 
and  verv  low  tones  being  well  perceived. 

In  all  of  these  tests,  dependence  must  be  placed  u])()n  the 
statements  of  the  jtatient,  and  much  of  the  accuracy  must  de- 
pend uj)on  the  intelligence  and  the  correctness  with  which 
he  answers  questions.  Methods  have  been  devised  to  avoid 
the  necessity  of  introducing  this  element  of  error  in  deter- 
mining the  location  of  the  morbid  j)rocess.  Thus  Lucaef 
conducted  an  exhaustive  series  of  experiments  w  ith  an  instru- 
ment which  he  termed  the  interference  otoscope.  The  device 
consisted  of  a  tuning  fork,  the  vibrations  of  which  were  main- 
tained at  a  constant  amplitude  by  the  action  of  the  electric 
current.  The  fork  was  placed  so  that  its  vibrations  were 
collected  by  a  funnel-shaped  receiver,  the  smaller  end  of 
which  was  prolonged  as  a  flexible  tube  terminating  in  three 
branches.  One  of  these  terminal  divisions  was  inserted  into 
each  external  auditory  meatus  of  the  patient,  while  the  third 
was  inserted  into  either  auditorv  canal  of  the  examiner.  It  is 
thus  seen  that  the  vibrations  of  the  fork  would  be  conveyed 
through  the  tubes  to  both  ears  of  the  patient  and  to  the  ear 
of  the  examiner  as  well.     Any  obstruction  in  the  sound-con- 


*  Op.  cit.,  p.  395. 

f  Arch,  fiir  Ohrenheilk.,  vol.  iii,  p.  186. 


l66  FUNCTIONAL    EXAMINATION. 

ducting  apparatus,  as  we  know,  renders  the  transmission  of 
vibratory  impulses  more  difficult  in  proportion  to  the  degree 
of  obstruction,  and,  as  the  sound  perceived  by  the  examiner 
represents  not  only  the  vibrations  coming  directly  to  his  ear 
— from  the  fork — but  also  the  waves  reflected  from  the  ears 
of  the  patient,  it  would  be  possible,  by  alternately  closing 
the  tubes  upon  the  one  side  and  the  other,  to  estimate  any 
variation  in  the  intensity  of  the  sound  thus  produced.  It  is 
evident  that  the  sound  would  be  more  intense  in  proportion 
as  the  transmitting  mechanism  offered  an  obstruction  to  the 
inward  progress  of  the  impulses.  In  other  words,  the  more 
intense  sound  should  come  from  the  poorer  ear  if  the  conduct- 
ing apparatus  alone  were  affected.  Great  care  must  be  taken, 
in  conducting  this  test,  that  the  tubes  of  the  binaural  stetho- 
scope shall  be  cxactlv  equal  in  length,  and  also  that  the  ear- 
pieces shall  fit  the  meatus  exactlv,  in  order  that  all  of  the 
reflected  waves  mav  pass  backward  through  tiie  tube  and  into 
the  ear  of  the  examiner.  This  test  has  been  somewhat  modi- 
fied bv  Jankau  *  in  the  following  manner : 

A  vibrating  tuning  fork  is  placed  upon  the  vertex  of  the 
patient  and  the  receiver  is  dispensed  with,  while  the  auscul- 
tation tube  of  the  examiner  terminates  in  a  Y  tube,  the  free 
extremities  of  which  join  the  tubes  occluding  the  external 
canals  of  the  patient  as  in  the  other  instrument.  Under  these 
conditions  the  tone  conveyed  to  the  ear  of  the  examiner  is 
re-enforced  by  the  action  of  the  external  meatus,  which  acts 
as  a  resonator,  augmenting  the  sound  of  the  fork.  Under 
normal  conditions,  both  ears  being  the  same,  there  is  no  ob- 
struction to  the  vibrations  through  the  cranial  bones  to  the 
labyrinthine  fluid,  from  which  they  are  communicated  to  the 
ossicular  chain,  to  the  membrana  tvmpani,  and  in  turn  to  the 
air  in  the  canal,  which  re-enforces  the  sound  bv  its  action  as 
a  resonator.  If,  however,  an  obstruction,  due  to  an  increased 
tension  of  the  labvrinthine  fluid,  exists,  which  prevents  the 
passage  of  the  sound  waves  outward  from  the  labvrinth  to 
the  ossicular  chain,  this  resonant  action  will  to  an  extent  be 
diminished,  and  the  observer  will  perceive  that  the  sound 
from  this  side  is  less  intense.  In  other  words,  the  weaker 
sound  will  come  from  the  jxjorcr  car,  if  the  impairment  of 
function  is  due  to  increased   labvrinthine  tension.     If,  on  the 

*  Arch,  fiir  Olirenheilk.,  vol.  xxxiv,  p.  190. 


C.ALXANIC    Rl. ACTION.  167 

Other  hand,  the  vibrations  of  the  labyrinthine  fluid  are  not 
impeded,  but  the  tympanic  structures  external  to  the  stapes 
are  in  a  state  of  increased  tension,  the  resonant  action  of  the 
canal  will  be  increased  on  account  of  the  rigidity  of  its  walls, 
the  condition  favoring-  a  more  perfect  reflection  of  the  sound 
waves  ;  in  which  case  the  stronger  tone  will  come  from  the 
poorer  ear.  Jankau's  clinical  investigations  and  experiments 
seem  to  confirm  this  supposition. 

The  difficulty  of  avoiding  errors  of  experiment  are  so  con- 
siderable here  that  the  chief  use  of  the  procedure  will  be  as  a 
confirmatory  test. 

Tlic  Galvanic  Reaction  of  the  Auditory  Xcrve. — As  has  been 
stated,  the  auditory  nerve  differs  very  little  from  other  spe- 
cial or  general  structures  of  a  similar  nature.  In  the  study 
of  nervous  diseases  in  general,  great  attention  has  been  paid 
to  the  reactions  of  nerve  tissue  under  electrical  stimulation, 
and  the  changes  in  the  electrical  phenomena  which  morbid 
processes  cause.  Special  attention  was  given  by  Brenner  * 
to  the  effect  produced  bv  the  galvanic  current  upon  the  audi- 
tory nerve,  and  he  was  the  first  to  formulate  the  reaction  of 
the  normal  acoustic  nerve.  According  to  this  auth(^r.  uj)on 
the  application  of  the  galvanic  current,  a  sharp  sound  is  [)ro- 
duccd  at  the  moment  of  cathodal  closure  (c.  c).  which,  as  the 
current  is  continued,  is  transformed  into  a  c<»ntinuous  sing- 
ing sound  (c.  d.).  At  the  moment  of  cath<jdal  opening  (c.  o.) 
the  singing  ceases  abruptly.  Anodal  closure  (a.  c.i  [)roduces 
no  sound,  and  the  period  of  silence  is  continued  as  long  as 
the  current  passes  in  this  direction  (a.  d.).  Upon  anodal 
opening  (a.  o.)  a  low  sound  is  perceived  similar  in  quality  to 
that  heard  at  cathodal  closure,  but  of  less  intensity.  The 
strength  of  the  current  in  milliamj)ercs  represents  the  strength 
of  the  current  necessary  to  excite  the  acoustic  nerve.  If  after 
cathodal  closure  the  current  is  allowed  to  pass  for  a  few  sec- 
onds and  the  circuit  is  then  broken,  it  will  be  found  that  a 
current  of  less  intensity  is  necessary  to  excite  an  auditory  im- 
pression than  m  the  first  instance.  The  same  follows  if  the 
experiment  is  repeated  for  the  third  time.  These  variations  in 
the  strength  of  the  current  represent  the  primary,  secondary, 
and  tertiary  electric  irritability  of  the  auditory  nerve.     Under 


*  Untersuch.  u.  Beobachtungen  iiber  die  Wirkung  elektrischer  Strome  auf  das  Ge- 
hororgan,  Leipzig,  1868. 


l68  FUN'CTIONAL    EXAMINATION. 

ordinary  conditions,  the  nerve  requires  so  strong  a  current  to 
produce  an  auditory  impression  upon  it,  as  to  make  it  neces- 
sary to  conclude  the  experiment  before  the  reaction  is  ob- 
tained, on  account  of  the  pain  which  the  passage  of  the  cur- 
rent causes.  The  primary  irritability,  however,  should  not 
fall  below  six  milliamperes.  In  conditions  of  hypcra^sthesia 
the  primary  irritability  will  be  found  much  below  this  figure; 
while  in  cases  of  torpidity  of  the  nerve  this  normal  limit  is 
exceeded. 

In  the  absence  of  a  large  galvanic  battery,  a  simple  storage 
battery  of  from  four  to  eight  volts  furnishes  sufficient  current 
to  enable  one  to  make  all  of  these  tests  ;  it  is  necessary  to  com- 
bine in  the  circuit  a  reliable  rheostat  and  a  milliampere-mctre. 
The  current  obtained  in  this  manner,  while  not  of  great 
strength,  is  ample  for  the  purpose  and  possesses  the  advan- 
tage of  not  being  liable  to  the  variations  in  intensity  which  we 
so  often  find  when  the  dip  cell  is  used. 

Some  of  the  dry  cells  now  offered  for  sale  also  furnish  a 
convenient  means  for  securing  a  reliable  current  with  the  ex- 
penditure of  but  a  trifle.  Twelve  dry  cells  furnish  a  current 
sufficient  for  taking  the  galvanic  reactions  of  the  auditory 
nerve.  In  no  instance  should  the  ear  be  subjected  to  the 
action  of  the  electric  current  for  purposes  of  either  diagnosis 
or  therapeusis  without  including  a  rheostat  in  the  circuit,  by 
which  its  intensity  can  be  controlled.  In  employing  the  gal- 
vanic current  as  a  means  of  diagnosis  it  is  also  essential  that 
a  milliampere-metrc  be  added  to  estimate  quantitatively,  the 
current  causing  sj)ccial  phenomena. 

Considerable  dilTcrence  of  opinion  exists  as  to  the  proper 
method  of  applying  the  electrodes  in  conducting  the  tests. 
According  to  the  choice  of  the  examiner,  the  electrode  applied 
to  the  car  may  be  placed  either  upon  the  side  of  the  face  just  in 
front  of  the  tragus,  or  it  may  be  placed  over  the  entrance  of  the 
canal,  which  has  been  filled  with  water  ;  or  the  canal  may  be 
filled  \yith  water  and  the  electrode  immersed  in  this,  care  be- 
ing taken  that  it  is  insulated,  so  as  not  to  come  in  contact  with 
the  walls  of  the  meatus.  The  circuit  is  completed  by  means 
of  a  broad  electrode  placed  upon  an  indifferent  region,  some- 
times on  the  back  of  the  neck  and  sometimes  held  in  the  hand. 

The  experiments  of  Gradenigo  *  are  of  considerable  in- 


Arch,  fiir  Ohrenheilk.,  vol.  xxvii,  p.  i. 


GAIAAMC    KllACriON.  169 

terest,  in  that  they  demonstrate  not  only  the  reaction  of  the 
acoustic  nerve  to  electrical  stimuli,  but  also  seem  to  prove  con- 
clusively that  auditorv  hvperresthesia  is  not  the  cause  of  the 
lateralization  of  the  tuning  fork  in  affections  of  the  middle  ear. 
The  investigations  of  this  writer  show  that  while  the  sound 
may  be  referred  to  the  hyper^esthetic  side,  it  is  often  lateralized 
when  no  hyperjesthesia  exists,  or  the  sound  mav  be  referred 
to  one  side  even  when  hyperaisthesia  exists  upon  the  other. 

Another  interesting  result  demonstrated  by  these  experi- 
ments is  the  fact  that  electric  stimulation  of  the  nerve  of  one 
side  often  increases  the  susceptibility  of  the  opposite  nerve  to 
the  action  of  the  current. 

The  remarks  made  concerning  the  electric  acoumeter  ap- 
plies to  the  emj)K)ymcnt  of  the  galvanic  tests — viz.,  that  al- 
though \aluable.  tiic  method  is  too  complicated  to  achuit  of 
general  use,  and  tlie  amount  of  additional  information  gained 
by  it  scarcelv  comj)cnsatts  for  the  extra  time  recpiired  for  its 
application.  \Vc  shall  therefore  relv  i)rinci{»allv  ujion  the 
])o\ver  of  audition  for  lower  notes,  the  hearing  ]»ower  lor  high 
notes,  the  absolute  bone  conduction  and  a  quantitative  ckter- 
inination  of  the  integritv  of  audition  bv  means  of  the  whis- 
per, in  arriving  at  an  opinion  concerning  the  location  of  anv 
Ifsjon.  To  these  mav  ])roperlv  be  added  either  Kitelberg's 
test  or  that  of  Gradenigo,  to  afTord  information  concerning  the 
ease  with  which  the  nervous  aj)paratus  becomes  exhausted  by 
prolonged  stimulation  as  comjiared  with  the  normal  organ 
under  similar  conditions.  The  data  furnished  by  these  latter 
tests,  however,  mav  be  frequently  quite  as  well  obtained  by 
observing  closely  the  behavior  of  the  patient  during  a  pro- 
longed functional  examination.  When  the  perceptive  appa- 
ratus is  in  an  asthenic  condition,  it  will  be  found  that  pro- 
longed qualitative  and  quantitative  tests  are  followed  by  a 
marked  diminution  in  the  abilitv  of  the  patient  to  perceive  a 
given  sound,  demonstrating  very  clearly  that  the  continuous 
stimulation  to  which  the  nerve  tissues  have  been  subjected, 
has  ablated  their  power  to  a  marked  extent. 

It  should  be  remembered  that  under  normal  conditions 
excitation  of  the  perceptive  tract  renders  it  more  sensitive  in 
responding  to  stimuli,  as  is  clearlv  shown  bv  the  experiments 
of  Urbantschitsch.*    The  statement  alrcadv  made  in  consider- 


*  Archiv  fur  Ohrenheilk.,  vol.  xxxiii,  p.  186. 


I70  FUNCTIONAL    EXAMINATION. 

ing  the  electrical  irritability  of  the  auditory  nerve  is  no  less 
true  of  the  response  of  the  nerve  structures  to  sonorous 
stimuli — that  is,  a  sounding  body  allowed  to  vibrate  before 
one  ear  may,  to  a  marked  degree,  influence  the  perceptive 
power  of  the  organ  on  the  opposite  side.* 

*  Urbantschitsch,  Lehrbuch  der  Ohrenheilkunde,  Vienna,  1890,  p.  417. 


DISEASES   OF   THE   CONDUCTIXG  AriWRATUS. 


DISEASES     OI' 
THE    CONDLCILNC.    APl'AKA  1  L  S. 


/.     /)/S/£.iS/£S   OF    THE   AURICLE. 
CllAI'Tl-K    \'. 

CONfJKMlAI.    MAM  <  )kM.\  rioNS    OF    THK    AUKICI.K. 

Any  inaltorination  ut  llic-  external  car  at  birlli  has  lor  a 
lon<^  tinie  been  considered  somewhat  indicative  of  the  pres- 
ence of  some  corrcsjiondini!^  mental  impairment.  That  mental 
weakness,  defects,  in  j)ervcrsi(jns  often  accompany  such  anom- 
alous anatomical  C(jnditions  is  a  matter  of  experience;  that  the 
two  always  occur  tog^ethcr.  however,  is  bv  no  means  true. 

Concernmf;^  the  classification  of  these  malformations  we  can 
divide  them  into  : 

I.  Deformities  (jf  particular  j)arts  of  the  auricle,  the  exter- 
nal ear  as  a  whole  maintaining^  its  general  outline. 

II.  .\\\  anomalous  shape  or  a  mal|)osition  ot  the  entire 
auricle,  includins^  variations  in  si/e,  or  in  the  anj^le  ot  attach- 
ment to  the  skull. 

ill.  The  presence  of  some  anomalous  anatomical  condi- 
tion, such  as  certain  supeniuiuerar\-  appendages,  listulrL',  etc., 
in  the  region  of  the  ear,  the  auricle  being  |)rcsent  either  in  its 
normal  form  or  being  more  or  less  altered  in  shape. 

\\ .  A  condition  of  asvmmetrv  between  the  organs  of  the 
opposite  sides. 

Since  the  last  group  is  of  but  little  importance,  it  may  be 
disposed  of  in  a  few  words.  Occasionally  we  find  one  auricle 
either  very  large,  or.  on  the  other  hand,  while  normal  in  con- 
tour, uniformly  reduced  in  size  without  any  other  departure 
from  the  normal  standard.  Such  a  condition  can  be  looked 
upon  only  as  a  "  freak  of  Nature,"  and  is  in  no  way  associated 
with  mental  impairment,  nor  can  any  definite  cause  be  as- 
signed for  its  existence  in  many  cases.     When  met  with  in 

fi73) 


1-4     CONGENITAL    MALFORMATIONS    OF    THE    AURICLE. 

the  adult,  a  careful  investigation  of  the  previous  history  may 
reveal  some  injurv  in  childhood  which  had  been  forgotten, 
and  the  deformity,  which  at  first  was  considered  congenital, 
rcallv  depends  upon  a  traumatic  cause. 

I.  Deformities  of  particular  parts  of  the  auricle,  the  ex- 
ternal ear  as  a  whole  maintaining  its  general  outline. 

Anoinaliis  of  t/hllilix. — The  so-called  Darwinian  ear  and 
the  satyr  ear  are  examples  of  moderate  anomalies  of  this 
character.  Wagenhaiiser  *  has  reported  an  instance  in  which 
the  upper  part  of  the  helix  was  absent  on  both  sides,  while 
Stetter-f  and  Schubert  :J:  have  reported  instances  in  which 
the  helix  was  abnormally  developed,  hanging  downward  and 
forward  as  a  flap.  In  Stetter's  case  the  antihelix  was  also  in- 
volved, and  the  deformity  was  so  extensive  as  to  obstruct  the 
entrance  to  the  meatus.  Relief  was  obtained  by  a  plastic 
operation. 

Anomalies  of  the  Antihelix. — When  the  antihelix  is  strong- 
ly developed  it  mav  project  beyond  the  line  of  the  helix  to 
such  an  extent  as  to  constitute  a  deformity.  This  is  most 
noticeable  when  the  auricle  is  viewed  from  behind.  Grade- 
nigo  has  observed  this  condition  more  frequently  in  females 
than  in  males,  and  considers  it  more  common  among  the 
criminal  and  insane  than  among  others.  In  a  case  observed 
by  the  author  the  antihelix  projected  fully  one  eighth  of  an 
inch  above  the  plane  of  the  helix,  and  a  condition  of  asvm- 
metry  was  also  present,  the  anomalous  condition  being  partic- 
ularly well  marked  u[)on  the  left  side ;  uj)on  this  side  also 
the  lobule  was  small  and  terminated  abruptlv  at  the  antitragus. 
The  intellect  was  normal. 

Sometimes  an  abnormal  development  of  the  superior  cms 
of  the  anthelix  pushes  the  helix  upward  and  forward,  giving 
rise  to  what  is  called  the  pointed  ear. 

Anomalies  of  the  Lobule. — The  lobule  is  abnormallv  large 
in  the  black  race,  reaching  such  a  development  among  the 
Kaffirs  that  by  piercing  it  in  a  particular  manner  a  sutiticientlv 
capacious  cavity  is  formed  within  the  lobule  to  serve  as  a 
pouch  for  carrying  tobacco. 

Occasionally  the  lobule  is  wanting,  as  in  a  case  reported 


*  Archiv  fur  Ohrenheilkiinde,  vol.  xix,  p.  55. 

f  Ibid.,  vol.  xxi,  p.  92. 

\  Ibid.,  vol.  xxii,  pp.  51,  52. 


ANOMALIES    OK     THK    TKAClUS.    KTC. 


1/5 


bv  Binder,*  while  Szenes  +  mentions  an  instance  in  wliich  the 
lobule  was  rudimentarv  ;  there  was  also  an  absence  of  the  ex- 
ternal auditory  meatus  and  a  faulty  development  of  the 
correspondinjr  side  of  the  lace.     Probably  the  most  frequent 


Fir,.  65. — Anomalous  division  of  the  antihelix  into  three  crura,  the  lower  of  which 
joins  the  crista  hclicis.     (From  a  [>hotograph.) 

deformity  in  this  rci^ion  is  cleft  lobule,  the  appearance  re- 
sembling^ closelv  that  seen  when  the  lobule  has  been  torn  in 
the  direction  of  its  loui^  axis,  by  the  forcible  removal  of  an  ear- 
ring from  the  ear. 

Auoiiialit's  of  the  Tnii^Ks. —  The  tra<;us  may  extentl  back- 
ward and  be  of  such  size  as  to  olTer  an  actual  obstruction  to 
the  entrance  of  sound  waves  into  the  meatus.  McBride:};  has 
observed  a  case  in  which  there  was  a  rudimentary  traijus  as- 
sociated with  other  abnormities  of  development. 

Anomalies  of  the  Autitragiis. — Malformation  here  is  exceed- 
inglv  rare.  Szenes*  observed  an  instance  in  which  two  spurs 
of  cartilage  projected  from  the  antitragus  into  the  canal. 


*Arch.  tiir  Psychiatrie,  1S87,  vol.  xx,  p.   2. 
f  Arch,  fiir  Ohrenheilkunde,  vol.  xxiv,  p.  185. 
J  Edinburgh  Med.  Journal,  April,  1881. 
*Arch.  fvr  Ohrenheilkunde,  vol.  xxvi,  p.  140. 


l-jd     CONGENITAL    MALFORMATIONS    OF    THE    AURICLE. 

II.  An  anomalous  shape  or  a  malposition  of  the  entire 
auricle. 

This  condition  in  its  most  pronounced  form  is  commonly 
known  as  microtia,  and  depends  upon  an  arrest  or  perversion 
of  the  process  of  development  which  results  in  so  complete  a 
malformation  that  the  distinctive  parts  of  the  external  ear  are 
no  longer  well  defined.  The  condition  may  be  unilateral  or 
bilateral,  and  is  frequently  associated  with  co-existent  malfor- 
mation of  the  deeper  parts  of  the  auditorv  apparatus.  For 
this  reason  the  condition  merits  special  attention.  Microtia  is 
associated  in  the  majoritv  of  instances   with  a  complete   ab- 


FiG.  66. — Microtia. 


sence  of  the  external  auditorv  meatus,  or,  in  cases  where  the 
canal  exists,  it  is  a  rudimcntarv  structure  ;  the  ossicular  chain 
is  frequently  poorly  dcvcl(){)cd  or  absent,  and  an  anomalous 
condition  is  common  in  the  labvriiith  as  well. 

The  deformity  mav  not  be  conhned  to  the  ear  alone,  but 
the  entire  side  of  the  face  mav  be  poorlv  developed.  The  ap- 
pearances vary  i^reatly  in  different  cases,  and  an  attempt  to 
describe  them  would  be  but  a  recital  of  particular  instances. 
Fii^.  66  is  a  drawing-  of  a  case  observed  bv  the  author.  In 
this  case  the  left  car  j)rescnted  an  anomalous  formation  of  the 


MICROTIA— MALPOSITION— TREATMENT. 


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antihclix  (see  Fic^.  65),  while  there  was  well-marked  microtia 
upon  the  right  side.  At  birth  the  right  ear  was  much  more 
deformed  than  the  picture  shows  it  to  be,  the  helix  at  that 
time  being  adherent  by  its  antero-superior  border  to  the  in- 
tegument in  front.  The  cutaneous  surfaces  separated  sponta- 
neously a  few  weeks  after  birth. 

Treatment. — Where  the  deformity  is  but  moderate  an  at- 
tempt at  correction  by  a  plastic  operation  may  be  made  i\\ 
early  childhood.  Regarding  any  attempt  to  form  an  artifi- 
cial meatus,  the  results  have  been  so  unsatisfactory  that  it  is 
seldom  desirable  to  operate  for  this  purpose.  If  the  rudi- 
mentary canal  is  present,  its  size  may  be  increased  by  surgical 
measures,  but  the  frequent  malformation  of  the  deeper  struc- 
tures commonly  renders  the  operation  futile  in  improying  the 
function  of  the  organ,  if  any  attempt  is  to  be  made  to  restore 
tlie  j)atency  of  the  canal,  it  should  be  delayed  until  the  j^alient 
is  old  enough  to  giye  information  in  regard  to  the  power  of 
sound  perception  either  through  the  air  or  through  the  cra- 
nial bones.  'J'he  techni(|ueof  the  operation  for  re-establishing 
the  meatus  will  be  described  under  jxilyotia.  The  j)lastic 
operation  on  the  auricle  for  the  relief  of  the  deformity,  how- 
ever, may  be  done  very  early.  When  a  high  degree  of  de- 
ff)rmity  is  present,  it  seems  advisable  to  excise  the  entire  au- 
ricle and  supply  its  place  by  an  artificial  device  rather  than 
attempt  its  restoration  by  surgical  measures,  which  will  at 
the  best  leave  a  misshapen  organ. 

From  a  practical  point  of  view,  one  of  the  most  interesting 
conditions  included  in  this  group  is  that  in  which  the  angle 
between  the  organ  and  the  lateral  aspect  of  the  skull  is  con- 
siderable. This  constitutes  a  deformity  amenable  to  treat- 
ment, and.  especially  in  the  female  sex,  one  for  which  we  are 
occasionally  consulted.  If  noticed  in  infancy,  or  even  in  early 
childhood,  the  simjjlcst  plan  for  correction  is  to  coat  the  pos- 
terior aspect  of  the  auricle  and  the  adjacent  cutaneous  surface 
of  the  head  with  colkjdion,  the  ear  being  then  pressed  to  the 
side  of  the  head  and  held  in  position  until  it  adheres.  If  nec- 
essary, several  light  strips  of  gauze  may  be  passed  over  the 
top  of  the  auricle,  holding  it  closely  to  the  side  of  the  head, 
and  fastened  with  collodion.  Persistence  in  this  plan  of  treat- 
ment will  usually  be  successful  in  correcting  the  condition. 
In  adult  life  little  can  be  gained  by  this  method,  and  resort 
must  be  had  to  some  operative  measure.  This  is  best  effected 
13 


178     CONGENITAL   MALFORMATIONS   OF   THE    AURICLE. 

by  removing  an  elliptical  segment  of  the  integument  from  the 
posterior  surface  of  the  auricle,  the  posterior  incision  passing 
just  beyond  the  line  of  attachment  to  the  auricle;  the  integu- 
ment is  then  dissected  up  from  the  posterior  surface  of  the 
auricle  for  a  sufficient  distance  to  permit  of  an  approxima- 
tion of  the  edges  of  the  wound.  Occasionally  it  is  necessary 
to  excise  a  segment  of  the  cartilaginous  framework  as  well,' 
in  order  that  the  ear  may  be  restored  to  the  proper  position. 
Usually  the  difficulty  is  sufficiently  well  overcome  by  approxi- 
mating the  edges  of  the  cutaneous  wound  without  removing 
any  of  the  cartilaginous  framework,  the  tension  due  to  the 
elasticity  of  the  cartilage  being  easily  overcome  by  the  su- 
tures. Under  aseptic  precautions  and  with  care,  a  perfect  po- 
sition can  be  secured.  General  anaesthesia  is  usually  neces- 
sary, although  it  is  possible  to  perform  the  operation  under 
local  anaesthesia.  It  is  well  to  operate  upon  the  two  organs 
separately,  using  the  first  as  a  standard  to  which  the  other  is 
made  to  conform. 

III.  The  presense  of  some  anomalous  anatomical  condi- 
tion, such  as  supernumerary  appendages,  fistulae,  etc.,  in  the 
region  of  the  ear,  the  auricle  being  present  either  in  its  nor- 
mal form  or  being  more  or  less  misshapen. 

Auricular  Appoidagcs,  the  General  1-onn  of  the  Ear  being 
preserved. — Abnormities  belonging  to  this  class  are  the  sim- 
plest with  which  we  have  to  deal.  The  most  frequent  region 
for  the  appearance  of  supernumerary  appendages  is  the  re- 
gion of  the  tragus.  A  case  of  this  sort  occurring  in  mv  own 
practice  is  shown  in  Fig.  dj.  The  prominent  cartilaginous 
process  constituting  the  deformity  was  located  just  above 
the  right  tragus,  was  about  three  fourths  of  an  inch  in  length, 
and  projected  forward  and  outward.  The  tragus  itself  could 
be  felt,  but  was  rudimentary. 

Barth  *  cites  an  instance  in  which  a  rudimentary  mam- 
mary gland  was  located  just  below  the  lobule  upon  one 
side. 

A  condition  belonging  to  this  class  constitutes  what  is 
known  as  "  fistula  congenita  auris  "  (Fig.  68).  Its  occurrence 
is  due  to  an  arrest  in  development  of  the  auricle  itself,  or,  as 
is  believed  by  some,  it  indicates  an  incomplete  closure  of  the 
first  visceral  cleft  during  foetal  life.     That  this  is  considered  a 

*  Virchow's  Archiv,  vol.  xii,  part  iii. 


AURICULAR   APPENDAGES— FISTULA. 


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somewhat  rare  malformation  is  probably  due  to  the  fact  that 
it  seldom  gives  rise  to  symptoms,  and  consequently  many 
cases  pass  unnoticed.  Four  cases  of  this  deformity  came 
under  my  own  observation  during  a  period  of  about  a  year. 
Fig.  68  represents  an  appearance  which  is  fairly-  typical.  The 
deformity  may  occur  either  upon  one  side  alone,  or  it  may  be 
bilateral.  In  one  of  my  cases  the  fistula  was  located  just  above 
the  tragus,  while  in  another  the  orifice  of  the  tract  was  situ- 
ated one  inch  above  this  point  and  presented  an  opening 
about  one  sixth  of  an  inch  in  diameter  through  which  a  probe 
could  be  passed  downward  and  inward  for  half  an  inch.     On 


Fig.  67. — Auricular  appendage. 


Fig.  63. — Fistula  congenita  auris. 
{a,  fistula.) 


the  opposite  side  the  site  of  the  fistula  was  occupied  by  a  shal- 
low depression  which  did  not  admit  even  the  finest  probe. 
Dccasionallv  a  slight  discharge  exudes  from  the  orifice  of  the 
fistula,  and  in  a  case  reported  by  Pfiiiger*  the  appearance  of 
a  purulent  discharge  from  such  a  source  was  alwavs  preceded 
by  acute  pain  in  the  ear.  Where  the  walls  of  the  sinus  se- 
crete, a  blocking  of  the  orifice  may  cause  a  retention  C3'st  of 
considerable  dimensions.  An  instance  of  this  is  cited  by  Ur- 
bantschitsch.+  The  most  common  location  for  such  fistulas 
is  in  the  vicinity  of  the  tragus,  although  they  are  occasionally 


*  Monatsschrift  fiir  Ohrenheilkunde,  1874,  No.  it. 
\  Lehrbuch  der  Ohrenheilk.,  third  edition,  l8go,  p.  94. 


l8o     CONGENITAL   MALFORMATIONS   OF   THE    AURICLE. 


met  with  in  the  helix  and  in  other  localities.     Burnett  *  states 
that  these  fistulce  may  lead  into  the  tympanic  cavity. 

Treatment. — The  appendages  should  be  removed  bv 
means  of  the  knife.  The  operation  is  exceedingly  simple. 
When  they  present  in  the  region  of  the  tragus  it  is  well  in 
excising  the  growth  to  form  a  tegumentary  flap  from  the  cov- 
ering of  the  anterior  surface  of  the  appendage,  which  can  be 
folded  backward  over  the  stump,  bringing  the  line  of  the  su- 
ture close  to  the  entrance  of  the  meatus,  as  the  cicatrix  is  less 
visible  in  this  position. 

Fistula  congenita  auris  demands  no  treatment  excepting 
in  those  instances  where  a  retention  cyst  has  been  formed  by 
the  occlusion  of  the  orihce  of  the  sinus.  This  condition  is  re- 
lieved by  a  simple  incision  and  the  evacuation  of  the  contents 
of  the  tumor,  the  walls  being  curetted  with  a  sharp  spoon  to 
secure  an  obliteration  of  the  cavitv. 

Polyotia. — This  term  is  apj>lied  to  a  congenital  deformitv 
in    which,   in    addition    to    microtia,    certain    supernumerary 

growths  are  met  with  in 
the  immediate  vicinitv  of 
the  car,  but  entirely  distinct 
from  the  deformed  auricle. 
Occasionally  they  occur 
with  a  perfectly  normal  au- 
/^  riclc,  the  fact  that  thev  are 
^•^  not  attached  to  it  distin- 
guishing them  from  the  au- 
ricular appendages  already 
described.  The  condition 
is  sometimes  associated  with 
congenital  aural  fistula,  as 
in  the  case  reported  by 
Biirkner.f  The  deformity 
mav  be  bilateral  or  unilat- 
eral, and  the  supplementarv 
organ  mav  present  a  varietv  of  shapes,  the  most  common 
being  that  of  a  small  wartlike  excrescence  situated  upon  the 
cheek  in  front  of  the  external  meatus.  When  this  multiple 
deformity   exists  there    is  usually   considerable   variation   in 


Fig.  69. —  Polyotia. 


*  A  Treatise  on  the  Ear,  Philadelphia,  18S4,  p  211. 
f  Archiv  fiir  Ohrcnhcilkunde,  vol.  xxii,  p.  20J. 


POLYOTI  A— TREATMENT.  iSl 

size  and  shape  between  the  members  of  the  group.  As 
already  stated,  a  normal  auricle  is  seldom  found,  although 
this  may  be  the  case.  The  condition  usually  occurs  in  con- 
nection with  microtia.  An  instance  of  this  kind,  observed  by 
me,  is  depicted  in  Fig.  69.  The  auricle  upon  the  affected  side 
was  represented  by  a  cutaneous  fold,  beneath  which  there  was 
a  cartilaginous  framework.  This  was  bent  forward  upon  the 
cheek,  covering  the  normal  site  of  the  meatus.  Upon  the  pos- 
terior surface  there  was  a  well-defined  groove  between  the 
cartilaginous  and  noncartilaginous  portion.  About  three 
fourths  of  an  inch  in  front  of  the  anterior  margin  of  this  de- 
formed auricle  was  a  small,  wartlike  prominence  representing 
a  second  and  rudimentary  i>inna,  it  being  situated  toofarante- 
riorly  to  rcj)rescnt  the  tragus.  The  hbro-cartilaginous  lamella 
already  mentioned  was  freely  movable,  and  just  beneath  its 
attachment  a  slight  depression  could  be  felt.  It  was  impossi- 
ble to  determine  wiicther  the  external  auditory  meatus  was 
present  or  not.     'J'he  ear  of  the  opposite  side  was  normal. 

The  remarks  made  under  microtia,  regarding  a  faulty 
development  or  a  comj)lete  absence  of  the  deeper  portions  of 
the  auditory  ajiparatus  ajtplv  ecjually  well  to  the  condition 
of  p)oh"i>ti;i. 

Treatment. — The  small  sui)ernumerary  appendages  are 
usually  easily  removed,  where  they  are  large  enough  to  con- 
stitute a  serious  deformity.  The  disfigurement  which  they 
cause  is  usually  slight,  however.  For  a  correction  of  the 
larger  malformed  mass  remaining,  a  plastic  operation  may  be 
attempted,  although,  as  in  microtia,  inore  satisfactory  results 
may  be  expected  by  a  complete  removal  of  the  deformed 
member,  its  place  being  supplied  by  an  artificial  substitute. 
Concerning  the  establishment  of  the  meatus  surgically,  the 
remarks  already  made  under  microtia  apply  equally  well 
here.  Even  if  it  is  possible  to  construct  the  meatus,  it  is 
scarcely  possible  to  secure  a  condition  of  permanent  patency. 
When  it  seems  desirable  to  attempt  this  operation  the  tech- 
nique is  as  follows  : 

The  field  of  operation  being  rendered  thoroughly  aseptic 
by  shaving  the  parts  and  cleansing  them  with  soap  and  water, 
and  subsequently  with  ether,  an  incision  is  made  just  behind 
the  attachment  of  the  deformed  pinna.  The  soft  parts  are 
divided,  exposing  the  bone,  after  which  the  anterior  flap,  in- 
cluding the  periosteum,  is  turned  forward  upon  the  cheek,  ex- 


l82     CONGENITAL   MALFORMATIONS   OF   THE    AURICLE. 

posing  the  region  normally  occupied  bv  the  external  auditory 
canal.  A  thorough  search  must  next  be  made  for  any  open- 
ing in  the  bone  which  may  represent  a  rudimentary  meatus, 
and  if  such  a  channel  is  discovered  it  should  be  cautiously  en- 
larged, by  means  of  either  chisels  or  burs,  the  latter  being 
propelled  by  an  ordinary  dental  engine  or  an  electric  motor. 
When  no  fistula  is  present  the  bone  may  be  cautiously  exca- 
vated in  the  region  corresponding  to  the  proper  position  of 
the  meatus.  Great  care  is  necessary  during  the  entire  pro- 
cedure, as  damage  may  be  done  to  important  adjacent  struc- 
tures. After  the  canal  has  been  formed  our  means  for  secur- 
ing its  patency  will  consist  in  the  insertion  of  an  aluminium  or 
rubber  tube,  which  will  separate  the  opposite  raw  surfaces  and 
allow  the  deep  parts  to  be  thoroughly  cleansed,  during  cica- 
trization. As  the  anterior  flap  when  replaced  would  cover 
the  newly  formed  channel,  it  should  be  perforated  over  the 
orifice  of  the  meatus  bv  making  two  incisions  bisecting  each 
other  at  right  angles.  Four  triangular  flaps  are  thus  formed, 
which  are  to  be  inverted  into  the  orifice  of  the  canal  and 
maintained  in  position  for  the  first  few  days  by  a  gauze  pack- 
ing, alter  which  the  metal  or  rubber  tube  already  mentioned 
is  to  be  employed.  As  soon  as  healthy  granulations  sjiring 
up,  a  method  which  suggests  itself  as  exceedingly  feasible 
would  be  Thiersch's  method  of  skin  grafting,  as  we  might 
thus  hope  to  secure  a  tegumentary  lining  to  the  passage  and 
prevent  its  contraction  during  cicatrization.  Such  an  opera- 
tion should  only  be  performed  at  the  earnest  solicitation  of  the 
parents,  in  the  case  of  a  child,  or,  if  the  patient  has  reached 
adult  life,  only  after  the  extreme  uncertainty  of  the  result  has 
been  fully  explained. 


CHAPTER    VI. 

WOUNDS   ANT)    INJURIES   OF   THE   AURICLE. 

It  is  seldom  that  \vc  see  incised  or  punctured  wounds  in 
this  particular  portion  of  the  body,  although  occasionally  we 
are  called  upon  to  treat  deformity  which  has  resulted  from 
wounds  of  this  character  inflicted  at  some  preceding  period. 
Here  the  ordinary  rules  of  plastic  surgery  will  enable  us  to 
secure  satisfactory  results.  In  performing  any  plastic  opera- 
tion upon  the  auricle  it  is  well  to  remember  that  when  the 
entire  thickness  of  the  external  ear  is  involved  all  sutures 
should  be  inserted  upon  the  posterior  surface  of  the  organ, 
accurate  approximation  of  the  cutaneous  edges  being  secured 
by  j>assing  the  stitches  dcej)ly  into  the  cartilaginf)us  frame- 
work, but  not  bringing  them  out  through  the  integument 
covering  the  anterior  surface. 

In  the  treatment  of  lacerated  wounds,  which  are  more 
frequentl}'  met  with,  we  should  attempt  to  save  as  much  tis- 
sue as  possible,  erring  rather  in  this  direction  than  in  that 
of  removing  any  part  which  possibly  may  possess  suflicient 
vitality  to  survive.  The  edges  of  the  wound  should  be 
thoroughly  cleansed,  and  as  a  primary  procedure  a  few  sutures 
may  be  applied,  holding  the  parts  as  nearly  as  possible  in 
their  normal  position.  It  is  a  simple  matter  after  the  circula- 
tion has  been  thoroughly  re-established  to  secure  a  more  exact 
approxiiTiation  and  relieve  whatever  deformity  may  be  present. 
As  the  auricle  is  composed  so  largely  of  cartilage,  any  severe 
bruising  of  the  tissue  is  likely  to  be  followed  by  a  sharp  peri- 
chondritis, and  unless  there  is  so  much  laceration  as  to  contra- 
indicate  the  plan,  it  is  well  to  anticipate  such  an  attack  by  the 
employment  of  cold  locally  for  the  first  twenty-four  hours 
after  the  injury  has  been  received  ;  subsequently  proper  atten- 
tion may  be  given  to  the  correction  of  deformity. 

Contused  wounds  of  the  auricle  without  laceration  of  the 
integument  are  of  frequent  occurrence.     Such  an  injury  re- 

(183) 


l84  WOUNDS   AND    INJURIES   OF   THE    AURICLE. 

suits  either  in  the  formation  of  a  hasmatoma — an  effusion  of 
blood  beneath  the  perichondrium — or  in  an  acute  perich(jn- 
dritis;  in  either  case  the  appearance  is  almost  identical.  The 
injured  region  is  occupied  by  a  somewhat  spherical  tumefac- 
tion, the  normal  outline  entirely  disa|)pearing.  Upon  palpa- 
tion we  discover  that  the  contents  of  the  tumor  are  evidently 
fluid.  The  surface  varies  considerably  in  color,  according 
to  the  particular  manner  in  which  the  injury  was  inflicted, 
and,  to  a  less  extent,  the  character  of  the  fluid  contained.  If 
this  is  blood,  the  surface  is  of  a  dull  deep-red  color,  while  if 
the  tumefaction  is  an  evidence  of  a  perichondritis,  with  an 
effusion  of  serum,  the  surface  is  of  a  much  lighter  tint,  being 
either  of  a  bright-rose  tinge,  or  occasionally  not  differing 
widely  from  the  integument  covering  the  unaffected  portion 
of  the  member.  Either  condition  may  remain  quiescent  for  a 
long  period  ;  may  disappear  spontaneously,  leaving  but  slight, 
or  marked  deformity  ;  or,  as  a  third  possible  termination,  the 
contents  may  suppurate  and  be  evacuated  spontaneously. 

Where  the  contents  consist  of  extravasated  blood  the  car- 
tilaginous framework  has  usually  been  fractured,  and  certain 
portions  will  almost  inevitably  become  necrotic  and  exfoliate 
with  the  production  of  considerable  deformity.  On  the  other 
hand,  a  simple  perichondritis,  where  no  fiacture  has  taken 
place,  may  disappear  without  seri(ouslv  changing  the  contour 
of  the  ear. 

Among  professional  wrestlers  and  boxers,  the  ear  is  fre- 
quently subjected  to  violence  not  sufficient  to  j^roduce  an 
acute  perichondritis,  but  enough  to  cause  a  mild  inflammation 
of  the  perichondrium,  so  slight  as  to  give  rise  neither  to  dis- 
comfort to  the  patient  nor  to  appreciable  deformity  immedi- 
ately after  the  injury.  This  chronic  inflammation  Anally  gives 
to  the  ear  an  appearance  which  is  somewhat  characteristic, 
known  as  "  prize-fighter's  ear,"  all  the  delicate  outlines  of  the 
anterior  surface  of  the  pinna  being  obliterated  by  the  deposit 
of  new  tissue  in  various  localities.  Occasionally  the  deformity 
reaches  such  a  high  degree  as  to  resemble  closely  the  condi- 
tion resulting  from  a  severe  acute  perichondritis  with  cartilagi- 
nous necrosis. 

Treatment. — The  treatment  of  an  acute  perichondritis  re- 
sulting from  contusion  consists,  first,  in  the  local  application 
of  cold,  provided  the  case  is  seen  within  twenty-four  hours  after 
the  injury  has  been  inflicted.     During  this  period  the  effusion 


TREATMENT   OF   CONTUSED   WOUNDS.  185 

of  serum  will  scarcely  reach  aiiv  considerable  amount,  and 
our  efforts  should  be  directed  to  the  purpose  of  |)revcntin*^ 
the  extravasation  of  fluid.     The  most  convenient   way  of  aj)- 

plyini^  cold  is  by  means  of  the  ice  ba^,  

sh(jwn  in  Fig.  70.     The  mastoid  region  I    '^     " 

should  be  covered  by  a  pad  of  cotton  /  m_*_ 

so  as  to  support   the  bag  against    the  - 

posterior  surface  of  the  auricle,   while       ' 
the  anterior  surface  may  be  covered  b\  /   ~" 

a  small  flat  ice  bag.  ,  ! 

When  seen  at  a  later  period  and  aftc :  \        / 

effusion  has  taken  place  efTorts  should  ^^ 

be  directed  toward  the  relief  of  the  de- 
formity, it  is  a  simple  matter  to  as- 
pirate the  efTused   fluid,  and   cause  the      ,-.^   -^     \      1        1  .„ 

'  '  riG.  70. — Aural  ice  bag. 

auricle  to  resume  a  perfectly  normal  ap- 
pearance, but  unfortunately  the  result  is  often  but  temporary, 
efTusion  taking  place  again  very  soon.  It  is  scarcely  neces- 
sary to  say  that  in  aspirating  the  fluid,  strict  antiseptic  pre- 
cauti<ins  as  to  the  instruments  and  the  field  of  oj)eration 
should  be  obscrvi-d.  After  the  operation,  it  is  well  to  insure 
close  contact  of  the  surfaces  which  have  been  separated  by 
the  elTusion.  by  means  of  a  clamj),  the  simplest  device  being 
an  ordinary  wocjden  sj)ring  clothes-j)in,  the  spring  being  so 
weakened  as  to  avoid  undue  pressure  upon  the  auricle,  while 
the  skin  is  protected  by  covering  the  anterior  and  j)osterior 
aspect  of  the  auricle  with  a  thin  pad  of  cotton.  vSuch  a  device 
may  be  worn  during  the  night,  and  may  j^revent,  to  a  certain 
extent,  the  rcapj)earance  of  the  effusi(jn.  The  pressure  excites 
a  slight  inflammation,  which  may  cause  adhesion  of  the  sep- 
arated surfaces  and  effectually  prevent  a  reaccumulatitm  of 
fluid.  Unfortunateh',  aspiration  is  not  attended  by  uniformly 
favorable  results,  and  after  it  has  failed  once  it  is  not  advis- 
able to  repeat  the  procedure. 

The  most  radical  and  satisfactory  plan  is  to  evacuate  the 
fluid  by  a  free  incision  so  as  to  expose  at  the  same  time  the 
interior  of  the  sac  sufficiently  to  permit  of  the  proper  treat- 
ment of  its  walls.  When  the  fluid  has  escaped  it  is  well  to 
curette  the  walls  of  the  sac  by  means  of  a  sharp  spoon,  after 
which  the  cavity  is  packed  with  iodoform  gauze,  the  aim  be- 
ing to  obliterate  the  space  by  granulation.  In  opening  the 
cyst,  care  should  be  taken  to  make  the  line  of  incision  conform 


l86  WOUNDS   AND    INJURIES   OF   THE    AURICLE. 

with  one  of  the  natural  folds  of  the  auricle,  thus  avoiding  any 
deformity  from  the  cicatrix.  With  proper  care  in  conducting 
the  operation,  so  as  to  avoid  suppuration,  recovery  without 
appreciable  deformity  is  the  rule. 

When  the  case  is  seen  at  a  still  later  period,  and  where  the 
injury  has  been  so  severe  as  to  result  in  cartilaginous  necrosis, 
the  only  procedure  available  is  that  of  incision.  This  should 
be  free  enough  to  permit  of  the  removal  of  all  disintegrated 
cartilage,  softened  areas  being  scraped  with  a  sharp  spoon 
until  completelv  healthy  tissue  is  reached.  The  subsequent 
treatment  is  the  same  as  that  advocated  above. 

We  have  spoken  of  the  various  wounds  which  mav  occur 
in  this  region,  and  we  need  mention  only  those  injuries  which 
mav  be  inflicted  either  by  the  potential  cautery,  by  chemical 
agents,  or  by  intense  cold.  Aside  from  the  destruction  of  tis- 
sue which  may  result  from  the  action  of  the  potential  cautery, 
or  strong  acids  or  alkalies  upon  the  auricle,  the  effects  pro- 
duced resemble  closelv  those  observed  after  severe  contusions, 
the  condition  being  essentially  one  of  perichondritis.  The 
wounds  caused  by  the  various  escharotic  agents,  cither  poten- 
tial or  chemical,  will  be  treated  upon  general  surgical  princi- 
ples. The  most  common  example  of  traumatism  comprised 
under  this  head  is  that  which  follows  exposure  to  intense  cold. 
When  the  ears  have  been  "  frozen,"  if  the  patient  presents  im- 
mediatclv,  the  parts  should  be  restored  to  their  normal  tem- 
perature graduallv,  by  the  application  first  of  pounded  ice  and 
then  of  cold  water,  the  temperature  being  increased  gradually 
to  avoid  a  sudden  disturbance  of  circulation  in  the  part  af- 
fected. The  ultimate  result  of  a  prolonged  exposure  to  cold, 
may  be  a  perichondritis  followed  by  cartilaginous  necrosis  and 
the  formation  of  sinuses  upon  the  anterior  and  posterior  sur- 
faces of  the  part.  Such  a  condition  is  to  be  dealt  with  surgi- 
callv  ;  the  sinuses  must  be  laid  open,  all  necrotic  tissue  re- 
moved, and  the  wound  be  allowed  to  heal  by  granulation.  If 
care  is  taken  but  little  deformity  need  result. 


CHAPTER   VII. 

CUTANEOUS   DISEASES   OF   THE    AURICLE. 

Intertrigo. — This  disease  is  observed  most  frequently  in 
vouiiij;-  children,  in  whom  it  is  caused  by  the  pernicious  habit, 
so  common  among  the  laity,  of  covering  the  cars  and  pressing 
them  close  to  the  side  of  the  head  by  means  of  a  tight  fitting 
cap  or  bonnet.  Among  the  poorer  classes  this  head-dress  is 
worn  for  a  great  portion  of  the  twenty-four  hours.  This  habit 
is  persisted  in  both  in  summer  and  winter,  the  result  being  that 
the  cutaneous  surfaces  of  the  posterior  aspect  of  the  auricle 
and  of  the  adjacent  integument  of  the  head  arc  kej)t  closely 
in  contact,  and  under  the  influence  of  the  natural  heat  and 
moisture  of  the  body.  The  result  is  a  desquamation  of  the 
superficial  epithelium  of  the  integument,  leaving  the  deeper 
layer  of  the  skin  ex[)oscd  to  the  air.  When  this  has  occurred 
over  a  small  area  the  local  process  becomes  intensified  from 
the  hypersecretion  which  takes  place  from  the  denuded  sur- 
faces, and  from  the  mechanical  irritation  produced  by  the  child 
in  its  efforts  to  relieve  the  intense  itching.  When  seen  by  the 
physician  the  adjacent  surfaces  of  the  auricle  and  of  the  side 
of  the  head  are  reddened  and  moistened  with  scrum,  which 
has  transuded  freely.  Tiiere  is  no  thickening  of  the  integu- 
ment over  the  affected  area,  a  fact  which  serves  to  distinguish 
the  disease  from  eczema,  which  soon  follows  unless  relief  is 
obtained. 

Aside  from  the  mechanical  causes  tending  to  produce  the 
disease,  it  is  probable  that  the  condition  is  more  commonly 
found  among  poorly  nourished  children  than  among  those 
who  are  w'ell  cared  for.  An  hereditary  predisposition  can 
scarcely  be  said  to  cause  intertrigo,  although  it  is  more  com- 
mon where  there  is  a  history  of  eczema  in  preceding  genera- 
tions than  where  such  history  is  wanting,  the  cutaneous  struc- 
tures apparently,  being  more  easily  influenced  by  a  slight  local 
exciting  cause,  as  mechanical  irritation,  than  would  otherwise 

(If?) 


1 88  CUTANEOUS   DISEASES   OF   THE    AURICLE. 

be  the  case.  Lack  of  proper  attention  to  cleanliness  is  nat- 
urally an  important  factor  as  well. 

The  treatment  consists  merely  in  keeping  the  denuded  sur- 
faces apart  and  protecting  them  from  traumatism.  All  head 
gear  which  would  keep  these  surfaces  in  contact  should  be 
discarded,  and  the  affected  areas  should  be  separated  by  a  thin 
layer  of  gauze  smeared  with  vaseline,  cold  cream,  or  other 
bland  oleaginous  medicament.  In  mild  cases  merely  dusting 
the  surfaces  with  Ivcopodium  powder,  finely  divided  zinc  ox- 
ide, zinc  oleate,  subnitrate  of  bismuth,  or  one  of  the  various 
toilet  powders  in  common  use,  will  ordinarily  be  sufficient  to 
correct  the  trouble.  These  applications  relieve  the  itching, 
and  consequently  the  child  docs  not  interfere  with  the  prog- 
ress of  the  disease  toward  spontaneous  recovery. 

Eczema. — This  disease  occurs  either  as  an  acute  or  chronic 
affection.  In  all  cases  probably,  there  is  either  some  heredi- 
tary predisposition,  such  as  a  goutv  or  rheumatic  diathesis,  or 
some  disordered  condition  of  the  prima:  via?,  irregular  habits 
of  life,  improper  or  insufficient  food,  etc. 

In  addition  to  a  predisposing  cause  some  local  exciting  in- 
fluence can  usually  be  made  out.  The  most  frequent  among 
these  is  a  discharge  from  the  external  auditory  meatus.  This 
condition,  while  in  the  vast  majority  of  cases  not  leading  to  an 
eczema  of  the  auricle,  causes  the  disease  in  those  predisposed 
to  it  on  account  of  the  reasons  named  above.  Among  chil- 
dren the  habit  of  covering  the  ears,  which  results,  as  already 
mentioned,  in  an  intertrigo,  is  frequently  responsible  for  the 
appearance  of  eczema. 

At  the  beginning  of  an  acute  attack  there  is  usually  a  feel- 
ing of  burning  or  discomfort  in  some  portion  of  the  auricle, 
usually  in  those  regions  where  the  cutaneous  surfaces  are 
somewhat  closely  opposed,  as  in  the  fossa  of  the  helix,  or  in 
the  fissure  intertragica,  or  at  the  orifice  of  the  meatus,  or  just 
behind  and  below  the  lobule.  In  children  the  region  imme- 
diately behind  the  ear  is  a  favorite  location.  The  feeling 
of  discomfort  soon  changes  to  one  of  intense  pruritus.  To 
relieve  this  the  patient  scratches  the  part  vigorouslv,  in- 
creasing rather  than  diminishing  the  local  hypera^sthesia. 
The  affected  surface  becomes  reddened,  soon  loses  its  super- 
ficial epithelial  laver,  is  moist  from  the  transudation  of  se- 
rum, or  in  the  later  stages  may  be  covered  with  crusts,  the 
removal  of  which  reveals  the  bright-red  color  of  the  inflamed 


ECZEMA— TREATMKNT.  1 89 

integument.  Instead  of  appearing  in  tliis  form,  we  occasion- 
ally have  a  group  of  vesicles  marking  the  affected  locality. 
These  vesicles,  by  inoculation  from  the  air,  soon  become  pus- 
tular, rupture,  and  give  rise  to  thick,  dirty  yelU)\vish  crusts, 
the  removal  of  which  is  frequently  attended  by  slight  hremor- 
rhage.  The  condition  constitutes  a  true  inflammation  of  the 
skin,  with  inhltration  of  its  deeper  layers.  Palpation  reveals 
this  fact,  the  integument  feeling  thick  and  somewhat  stifl  over 
the  entire  affected  area,  this  sensation  diminishing  graduallv 
as  the  healthy  integument  is  approached.  Where  a  local  cause 
is  the  most  prominent  factor  the  affection  is  unilateral,  but 
where  a  strong  constitutional  element  is  present  both  organs 
are  affected  as  a  rule.  When  the  disease  begins  upon  the  auri- 
cle the  affection  frequently  spreads  to  the  canal,  producing 
symptoms  which  will  be  described  later.  Frequently  after 
the  disease  has  persisted  for  some  time  the  su[)erficial  cervical 
lymphatics  are  enlarged. 

In  the  chronic  form  of  the  disease  the  entire  auricle  may 
be  involved,  ar  onlv  limited  j)ortions  of  it.  The  j>art  affected 
is  either  of  a  dull  pinkish  color,  the  surface  being  glossy  and 
polished,  as  though  tlie  skin  were  ver\  thin  and  tightlv  draw  n. 
or  in  other  cases  the  superficial  ej)itlRlium  is  cast  off  too  rap- 
idlv,  covering  the  surface  here  and  there  with  minute  whitish 
crusts  or  scales.  From  the  efforts  of  the  jiatirnt  t(»  relieve  the 
pruritus  these  scales  are  picked  off,  frecpientlv  causing  a  slight 
abrasion  of  the  surface,  and  increasing  the  activity  of  the  local 
process.  On  palpation  the  skin  feels  hard,  leathery,  and  thick, 
especiallv  where  the  patient  has  subjected  it  to  mechanical  irri- 
tation for  the  relief  of  the  itching.  Over  the  unbroken  surface 
the  thickened  integument  has  a  peculiar  smooth,  glossy  feel. 
De  Rossi*  has  described  a  case  in  which  the  entire  cartilagi- 
nous framework  of  the  auricle  became  necrotic  as  the  result 
of  chronic  eczema.  It  seems  probable  that  there  must  have 
been  some  underlving  cause  other  than  eczema,  to  produce 
this  destruction  of  tissue. 

Treatment. — Our  treatment  should  be  directed  to  the  re- 
moval of  the  local  exciting  cause  and  to  the  relief  of  the  con- 
stitutional element  of  which  the  disease  is  but  a  local  manifes- 
tation. Thus  in  the  acute  form  the  dietarv  of  the  patient  will 
frequentlv  need  correction,  and  the  elimination  of  certain  arti- 

*  Archiv  fiir  Ohrenheilkunde,  vol.  xxi,  p.  193. 


IQO 


CUTANEOUS   DISEASES   OF    THE    AURICLE. 


cles  of  food  or  the  addition  of  others  will  be  followed  by  sat- 
isfactory response  to  local  applications.  Diathetic  conditions 
must  be  managed  according  to  general  rules.  Moderately 
large  doses  of  alkalies,  either  in  the  forni  of  Rochelle  salts, 
bi-carbonate,  acetate,  or  citrate  of  sodium,  frequently  bring 
about  a  favorable  termination  where  local  treatment  alone 
has  been  useless. 

Turning  to  the  local  measures  to  be  employed,  any  dis- 
charge from  the  meatus  must  receive  proper  attention,  as  its 
presence  excites  the  cutaneous  infiltration.  In  the  acute  form 
our  first  efforts  are  to  relieve  the  subjective  symptoms.  To 
this  end  cold  applications  in  the  form-  of  evaporating  lotions 
are  of  service.  The  ordinarv  lead  and  opium  wash  is  a  favor- 
ite rcmcdv  in  the  acute  stage,  but  is  disagreeable  on  account 
of  the  color  which  it  imparts  to  the  skin,  and  because  of  its 
characteristic  odor.  Such  objections  do  not  apply  to  the  fol- 
lowing : 

IJ   Liquor  plumbi  subacctat 3  j  ; 

Bismuthi  subnitrat 3  ss.  ; 

MorphiucX i^r.  ij  ; 

Glycerini ^]  ; 

Aqua3  rosa" q.  s.  ad    3  viij. 

M.  Sig.  :  Apply  locally  as  a  wet  dressing.  Shake  before 
using. 

Instead  of  cold  applications,  better  results  are  sometimes 
obtained,  especiallv  where  the  thickening  is  inconsiderable  and 
the  discharge  from  the  surface  profuse,  by  employing  the  local 
remedy  in  the  form  of  a  powder  rather  than  as  a  solution. 
Here  we  may  use  the  oxide  of  zinc,  subnitrate  of  bismuth, 
starch,  lycopodium,  stearate  of  zinc,  etc.  Where  the  affection 
causes  a  most  intense  burning  of  the  skin  an  oleaginous  sub- 
stance is  the  most  desirable  vehicle.  The  following  ointment 
may  be  used  : 

5t   Bismuth   subnitratis 3  ij  ; 

Acidi  borici 3  j  ; 

Morphine gr.  j  ; 

Unguenii  zinci  oxidi 3  ss.  ; 

Petrolati q.  s.  ad    3  j. 

The  same  emollient  cfTcct  is  obtained  bv  cmploving  the 
stearate  of  zinc  in  combination  with  boracic  acid  and  sub- 
nitrate  of  bismuth,  and  the  oily  vehicle  is  avoided. 


ECZEMA— TREATMENT. 


191 


(^winf^  to  the  frequency  with  which  any  condition  attended 
with  an  increased  secretion  leads  to  the  development  of  an 
aspcrgillus  within  the  external  auditory  meatus,  it  is  advisa- 
ble it  the  disease  continues  for  any  considerable  period  and  in- 
volves the  parts  about  the  orifice  of  the  canal,  to  add  salicylic 
acid  to  any  oleai:^inous  preparation  which  may  be  employed 
as  a  local  application,  for  the  purpose  of  preventing  the  devel- 
opment of  such  a  parasite.  In  order  to  act  in  this  manner  the 
salicylic  acid  must  be  present  in  the  ointment  in  the  propor- 
tion  of  about  one  and  a  half  to  two  and  a  half  per  cent,  a  de- 
gree of  concentratic^n  which  does  not  act  as  an  irritant  to  the 
sensitive  cutis.  Eitelberg  *  has  employed  an  ointment  of  cre- 
olin  in  the  strength  of  about  two  per  cent  with  success. 
Where  crust  formation  is  a  prominent  feature  of  the  affection. 
as  occurs  when  the  acute  stage  has  passed,  all  aqueous  solu- 
tions are  contraindicated.  The  crusts  should  first  be  removed 
by  softening  them  with  olive  oil  or  vaseline,  after  which  the 
surface  may  be  medicated  either  with  one  of  the  above  oint- 
ments or  with  a  jiropcr  powder.  Salicylic  acid  in  alcohol  in 
the  strength  of  twenty  to  forty  grains  to  the  ounce  may 
occasionally  be  cmjiloycd,  although  in  mv  own  c\]icrience 
alcohol  has  j)rovcd  of  but  little  service  in  ec/enia  of  the 
auricle. 

It  should  be  remembered  that  the  exposure  of  the  denuded 
surface  to  the  air  is  undesirable,  and  that  the  affected  parts 
should  be  constantly  protected  by  some  non-irritant  or  slightly 
astringent  ointment,  such  as  the  oxide  of  zinc,  cold  cream,  or 
simple  vaseline. 

Nitrate  of  silver  in  aqueous  sohitiDU  has  many  advocates 
as  a  remedy  for  the  disease.  It  is  customary  in  using  this 
remedy,  to  begin  the  treatment  with  a  solution  of  about  ten 
grains  to  the  ounce,  the  strength  being  increased  until  the  de- 
sired effect  is  obtained.  I  have  seen  excellent  results  follow 
the  application  of  such  a  solution,  after  the  thickening  has  been 
reduced,  as  the  stimulating  effect  of  the  astringent  lotion  has- 
tens the  development  of  a  protecting  epithelial  layer. 

Where  the  thickening  of  the  integument  is  marked,  a  con- 
dition which  must  exist  when  the  disease  has  persisted  for  any 
length  of  time,  it  will  be  impossible  to  effect  a  permanent  cure 
without  relieving  the  affected  area  of  the  serous  infiltration. 

*  Wien.  med.  Press.,  1888,  No.  13. 


192 


CUTANEOUS   DISEASES   OF   THE    AURICLE. 


It  may  be  possible,  without  doing  this,  to  cause  a  temporary 
improvement,  and  to  succeed  in  causing  the  part  to  become 
covered  with  a  thin  layer  of  superficial  ejjithelium  ;  as  soon  as 
the  treatment  is  discontinued,  however,  the  disease  will  recur 
in  an  aggravated  form,  and  where  there  is  much  induration  we 
should  direct  our  attention  to  this  at  once.  For  this  purpose 
the  area  involved  may  be  thoroughly  scoured  with  green  soap, 
the  alkali  which  this  contains  causing  a  temporary  stimulation 
of  the  surface,  through  which  the  tissues  are  relieved  of  the 
serous  infiltration,  by  the  free  exudation  of  fluid.  This  process 
may  be  repeated  every  second  or  third  dav  until  the  integu- 
ment regains  its  normal  texture,  after  which  the  use  of  emol- 
lient and  astringent  applications  will  cause  a  speedy  return  to 
a  normal  condition,  and  effect  a  permanent  cure.  A  similar 
result  mav  sometimes  be  obtained  by  an  ointment  containing 
chrysarobin,  or  pvrogallic  acid,  or  oil  of  cade.  The  ammoni- 
ated  mercurial  ointiucnt  also  serves  a  similar  purpose.  Mv  best 
results  in  this  class  of  cases  have  been  obtained  by  employing 
the  acetum  cantharidis,  which  quickly  relieves  the  engorge- 
ment of  the  deeper  lavcrs  of  the  integument,  while  at  the  same 
lime  the  intense  pruritus  is  alleviated.  Considerable  care  is 
to  be  exercised  in  applying  this  remedy,  since  if  it  is  used  in 
too  large  quantities  the  surface  may  be  blistered  and  the  pa- 
tient be  subjected  to  considerable  discomfort.  The  acetum 
cantharidis  is  to  be  applied  to  the  afTected  areas  by  means  of 
a  cotton  mop,  the  parts  being  first  lightly  brushed  with  the 
solution  and  the  application  repeated  on  the  following  day  if 
no  effect  has  been  produced.  As  a  result  of  the  application 
of  this  remedy  a  free  serous  transudation  takes  place,  and  soon 
the  parts  become  covered  with  a  normal  epithelium,  the  ex- 
uded serum  drying  upon  the  surface  in  the  form  of  a  thin  yel- 
lowish crust,  which  can  either  be  removed  with  the  aid  of  the 
forceps  on  the  second  dav,  or,  if  left  to  itself,  will  become  dis- 
integrated and  exfoliate  as  a  thin,  scaly  desquamation.  If  the 
action  of  the  cantharidcs  is  too  vigorous  the  application  of 
some  oleaginous  preparation  for  twenty-four  hours  will  re- 
lieve all  discomfort.  The  application  of  the  cantharides  may 
be  repeated  at  frequent  intervals  until  the  infiltration  has  en- 
tirely disappeared. 

We  should  add,  in  closing,  that  constitutional  medication 
and  local  applications  must  go  hand  in  hand  in  combating 
the  affection  under  consideration. 


PEMPHIGUS— HERPES.  193 

Pemphigus. — This  is  a  somewhat  rare  cutaneous  disease, 
but  is  occasionally  observed.  Its  characteristic  appearance 
differs  in  no  way  from  pemphigus  developing  upon  other 
portions  of  the  body.  The  condition  manifests  itself  in  the 
formation  of  large  blebs  filled  with  a  clear  serous  fluid.  Al- 
though the  favorite  site  for  the  development  upon  the  auricle 
is  the  margin  of  the  heli.x  and  the  lobule,  it  is  occa.'-ionallv 
found  in  other  situations. 

From  local  infection,  this  serous  fluid  mav  bect)me  turbid, 
but  it  is  rarely  purulent.  The  bulku  rupture  spontaneously 
at  the  end  of  a  few  days,  and  if  the  walls  are  not  destroved, 
j)rotcct  the  denuded  area  which  they  cover,  and  are  subse- 
(piently  cast  off  in  the  form  of  scales,  their  former  site  being 
marked  by  a  slight  redness  of  the  integument.  On  the  other 
hand,  if  the  sac  is  entirely  destroyed  an  eroded  surface  is 
left.  This  seldom  persists  for  any  length  of  time,  becoming 
rapidly  dry,  the  integument  remaining  slightly  reddened  in 
this  situation.  Xo  pain  attends  these  local  manifestations,  and 
the  disease  is  of  importance  simply  on  account  of  the  fact  that 
the  patient  is  ordinarily  afflicted  by  several  successive  crops 
of  bulku,  which  are  a  source  of  annoyance  because  of  the  dis- 
figurement. 

The  best  results  are  obtained  bv  j>uncturing  the  thin  en- 
velope which  incloses  the  fluid,  and  coating  the  collapsed  sac 
with  a  lavcr  of  flexible  collodion  to  protect  the  surface  be- 
neath. The  internal  use  of  arsenic  is  the  best  prophylactic 
measure  against  recurrence. 

Herpes. — This  condition  is  extremelv  rare,  although  a 
search  through  otological  literature  furnishes  us  with  quite  a 
number  of  instances  of  the  affection.  The  disease  is  esscn- 
tiallv  the  same  as  herpes  zoster,  differing  from  it  only  in  the 
l(3calitv  of  the  cutaneous  manilcstation.  Neurotic  subjects 
are  particularly  predisposed  to  the  affection,  although  it  oc- 
casionallv  attacks  those  in  perfect  health.  Indiscretions  in 
diet,  faulty  assimilation,  and  improper  and  insufficient  food 
may  be  mentioned  among  the  other  predisposing  causes.  As 
an  exciting  cause,  exposure  to  cold  is  the  most  important  ; 
while  in  a  case  reported  by  Chatellier,*  it  was  caused  by  local 
irritation.  The  particular  pathological  condition  is  obscure, 
but  probably  consists  in  a  neuritis  of  the  trophic  nerves  which 

*  Annales  des  mal.  cle  I'oreille.,  1886,  No.  6. 
14 


194 


CUTANEOUS   DISEASES   OF   THE    AURICLE. 


supply  the  parts  involved.  These  are  the  auricularis  magnus 
and  the  auriculo-temporal,  the  former  coming  from  the  cervi- 
cal plexus,  the  latter  from  the  third  branch  of  the  trigeminus. 

The  onset  of  the  affection  is  commonlv  marked  by  severe 
constitutional  disturbance,  such  as  an  acceleration  of  the  pulse, 
an  elevation  of  the  temperature,  varying  in  degree  from  ioo° 
to  102°  Fahr.,  or  even  103°  Fahr.,  headache,  and  a  feeling  of 
general  lassitude.  The  characteristic  subjective  evidence  is 
the  intense  neuralgic  pain,  which  may  be  confined  to  the  ear 
or  may  spread  over  the  entire  side  of  the  face,  following  the 
general  area  of  distribution  of  the  nerves  involved.  Since  the 
pain  may  precede  the  eruption  by  several  davs,  the  exact  diag- 
nosis is  often  difficult.  When  the  eruption  appears,  we  find 
the  portion  of  the  auricle  involved  covered  with  groups  of 
vesicles  which  rise  from  a  reddish  base  and  are  filled  with 
clear  serum.  Occasionally  they  coalesce  and  form  a  bullous 
eruption.  The  anterior  surface  of  the  auricle  is  generally 
the  region  attacked,  although  in  a  case  reported  bv  Green  * 
the  posterior  surface  was  involved.  The  manifestation  is 
ordinarily  unilateral,  but  Wagenhaiiserf  observed  an  instance 
in  which  it  was  bilateral.  Although  usually  confined  to  the 
auricle,  the  affection  may  spread  to  the  canal.  A  few  davs 
after  their  appearance  the  vesicles  rupture,  their  envelope 
becomes  dry  and  is  cast  off  in  the  form  of  minute  scales,  leav- 
ing the  integument  beneath  of  a  somewhat  reddened  or  brown- 
ish hue. 

In  cachectic  individuals  superficial  ulccratiiMi  may  persist 
for  a  considerable  time  over  the  site  of  the  vesicles.  The 
constitutional  symptoms,  which  have  been  so  marked  before 
the  vesicles  appear,  usuallv  abate  when  the  eruption  becomes 
well  marked,  although  this  is  not  an  invariable  rule,  and  the 
general  symptoms  may  persist  for  a  long  period  after  the  local 
lesion  has  entirely  disappeared. 

Since  diathetic  conditions  are  a  prominent  causative  factor, 
the  patient  seldom  escapes  with  a  single  attack  of  the  dis- 
ease, a  second  or  third  recurrence  being  the  rule. 

Treatment. — Measures  directed  toward  the  relief  of  the 
condition  divide  themselves  into  those  for  the  control  of  the 
constitutional  symptoms  and  those  for  the  relief  of  the  local 


*  American  Journal  of  Otology,  vol.  iii,  No  2. 
•f  Arch,  fiir  Ohrenheilkunde,  vol.  xxvii,  p.  159. 


HERPES.    TREATMENT— SYPHILIS.  I95 

manifestations.  Our  first  measure  should  be  a  thorougii  cleans- 
ing of  the  alimentary  canal  by  a  brisk  saline  purge,  the  dietary 
of  the  patient  being  at  the  same  time  restricted  so  as  to  em- 
brace only  the  simplest  articles  of  food.  When  the  febrile 
movement  is  prominent  the  ordinary  antipyretics,  such  as 
antifebrin,  antipyrifi,  or  phenacetin,  should  be  administered, 
the  last-named  drug  exerting  a  favorable  influence  upon  the 
neuralgic  pain.  When  the  pain  is  of  unusual  severity,  aconitia 
in  doses  of  one  five  hundredth  of  a  grain,  repeated  every 
hour  fcjr  three  or  four  doses  until  the  constitutional  effects  of 
the  drug  are  felt,  after  which  the  interval  should  be  increased 
to  every  three  or  four  hours,  can  be  relied  upon  to  give  re- 
lief. Before  the  appearance  of  the  eruption,  cold  applications 
are  grateful.  Iced  cloths,  the  aural  ice  bag,  or  a  cold  lead- 
and-opium  lotion  may  be  employed  for  this  purpose.  The 
vesicles  are  best  treated  by  dusting  them  with  a  bland  powder 
to  prevent  their  early  ruj)ture,  and  where  they  are  C(jnfluent 
they  may  be  coated  with  collodion,  for  the  same  purpose. 

if  the  vesicles  are  infected  and  the  serous  fluid  becomes 
purulent,  their  contents  should  be  evacuated  by  means  of 
a  small  knife,  and  the  cxjiosed  area  be  dusted  with  icido- 
form,  iodol,  dermatol,  or  touched  lightly  with  a  solution  of 
nitrate  of  silver,  to  hasten  the  reparative  process.  An  emolli- 
ent ointment  containing  morphine  or  oj)ium  is  occasionally  of 
value.  It  has  been  suggested,  as  a  rational  means  of  con- 
trolling the  disease,  that  counter-irritation,  by  means  of  the 
actual  cautery  or  bv  vesicants,  be  cm|)loyed  over  the  trunk 
of  the  nerve  involved,  but  little  success  lias  attended  this 
method  of  treatment.  Regarding  the  subcutaneous  injection 
of  morfthine  over  the  affected  nerve,  it  should  be  remembered 
that  dishgurement  occasionally  follows  the  use  of  the  hypo- 
flcrmic  needle,  and  it  seems  that  the  advantages  are  not  suf- 
hcient  to  warrant  the  physician  urging  this  plan  of  treat- 
ment. 

Syphilis. — Any  syphilitic  lesi(^n  may  appear  upon  the  pin- 
na, although  a  cutaneous  manifestation  of  this  constitutional 
disease  is  of  rare  occurrence  in  the  region  under  consideration. 
Ziicker*  has  reported  an  instance  in  which  the  initial  lesion 
was  situated  upon  the  tragus,  the  part  being  of  a  dark-pur- 
plish color,  and  swollen  to  twice  the  natural  size.     There  was 

*Zeit.  fiir  Ohrenheilkunde,  vol.  xiii,  p.  167. 


196  CUTANl^OUS    DISEASES    OF    THE    AURICLE. 

concomitant    enlargement    of    the    submaxillarv   and  parotid 
glands. 

The  erythematous  syphiloderm  undoubtedl}''  attacks  the 
auricle  but,  since  it  causes  no  symptoms  to  call  attention  to 
its  presence,  is  usually  overlooked.  The  macular  eruption 
is  more  frequently  observed  on  account  of  the  distinctive 
appearance  to  which  it  ^ives  rise.  Occasionallv  it  spreads 
into  the  canal,  for  a  considerable  distance.  According  to 
Taylor,*  those  parts  supported  by  cartilage  are  more  fre- 
quently attacked.  The  papular  svphilide  is  of  interest  chiefly 
on  account  of  the  superficial  ulcerations  to  which  it  occa- 
sionally gives  rise.  In  an  instance  under  my  own  obser- 
vation such  an  ulceration  had  developed  at  the  junction 
of  the  lobule  with  the  integument,  just  below  the  mastoid. 
The  erosion  was  sharply  defined,  the  surface  only  slightly 
depressed,  and  but  a  slight  areola  was  present.  The  appear- 
ance resembled  an  intertrigo  so  closely  that  an  exact  diag- 
nosis was  made  only  upon  the  failure  of  the  erosion  to  clear 
up  under  ordinary  local  treatment,  and  its  prompt  disappear- 
ance upon  specific  medication. 

A  specific  eruption  of  a  tubercular  character  is  occasion- 
ally observed.  The  ulcerated  areas  are  covered  by  large 
crusts,  upon  the  removal  of  which  the  outline  of  the  affected 
portion  is  seen  to  be  sharply  defined.  Either  the  anterior  or 
the  posterior  surface  of  the  external  car  may  be  attacked.  A 
correct  diagnosis  is  possible  by  bearing  in  mind  the  sharph 
defined  outline  of  the  specific  ulceration,  its  reddish  color  in 
contradistinction  from  the  irregular  grayish-white  color  of 
tubercular  or  lupoid  ulceration,  its  slightly  depressed  surface, 
which  is  comparatively  smooth,  in  contradistinction  to  the 
nodular  appearance  observed  in  the  affections  just  named,  and 
the  history  of  an  antecedent  specific  infection. 

The  appearance  of  a  gummy  tumor  in  the  external  car  is 
one  of  the  rarest  manifestations  of  the  constitutional  poison. 
Baratouxf  has  reported  an  instance  in  which  the  infiltration 
was  multiple.  The  deposit  presents  as  a  hard,  smooth  tumor, 
of  a  deep-red  color,  and  in  the  early  stages  does  not  fluctuate 
upon  palpation.  At  a  later  period  the  centre  of  the  mass  be- 
comes necrotic,  the  disintegrated  tissue  finally  breaking  down 


*  Cited  by  Rupp,  Journal  of  Cutaneous  and  Genito-Urinan-  Diseases,  Oct.,  1891. 
f  Cited  by  Rupp,  Ice.  cit. 


SYPHILIS,    TREATMENT— LUPUS    ERYTHEMATOSUS.     19; 

to  form  pus,  which  is  evacuated  spontaneouslv.  unless  pre- 
vented by  the  institution  of  surgical  measures.  When  left  to 
itself  the  local  necrosis  results  in  the  development  of  a  deep 
ulcer. 

Treatment. — The  treatment  of  specific  lesions  of  the  auri- 
cle corresponds  to  that  of  similar  conditions  in  other  portions 
of  the  body.  If  a  gummatous  deposit  is  found  before  disin- 
tegration has  begun,  an  effort  should  be  made  to  cause  its 
absorption,  although  this  at  first  mav  seem  hopeless. 

Where  ulceration  has  taken  place  before  the  patient  comes 
under  observation,  large  doses  of  the  iodide  of  potassium 
should  be  at  once  administered,  and  for  a  time  local  treat- 
ment should  consist  simplv  in  keeping  the  parts  clean,  since 
the  reparative  process  which  this  drug  institutes,  frequently 
preserves  tissues  which  seem  so  disintegrated  that  the  surgeon 
would  have  no  hope  of  saving  them.  After  the  internal  med- 
ication has  been  persisted  in  for  a  short  time,  and  its  antag- 
onistic action  on  the  constitutional  infection  is  observed  in 
the  ulceration,  we  should  no  longer  hesitate  to  remove  all 
those  portions  which  are  manifestlv  be\t)nd  repair.  The  sharp 
spoon  is  to  be  called  into  requisition,  and  all  softened  tissue 
thoroughlv  scraj)e(l  awav.  The  dressing  is  carried  out  upon 
general  surgical  j)rincij)k'S. 

Lupus  Erythematosus. —  This  adcction  usuallv  attacks  the 
auricle  secondarilv,  some  other  portion  of  the  face  being  the 
starting  point.  At  first  it  jnesents  as  a  sharply  defined  red- 
dened area,  slightlv  elevated  above  the  surface  of  the  skin, 
over  which  it  soon  spreads  in  all  directions.  The  integument 
involved  becomes  thick,  injected,  and  separated  from  the  nor- 
inal  cutis  bv  a  rather  sharp  line  of  demarcation.  The  surface 
is  frequentlv  traversed  by  minute  veins.  Owing  to  the  in- 
terference with  the  blood  supply,  the  superficial  epithelium  is 
thrown  off  more  rapidlv  than  under  normal  conditions,  giving 
the  surface  a  glazed  appearance.  As  the  disease  encroaches 
more  and  more  upon  the  healthy  integument,  its  starting 
point  becomes  somewhat  depressed  and  of  a  lighter  color, 
owing  to  the  gradual  sclerosis  of  the  infiltrated  tissue.  The 
disfigurement  constitutes  the  entire  inconvenience  which  the 
affection  entails,  there  being  no  pain,  pruritus,  or  perversion 
of  sensation.  Although  usually  unilateral,  I  remember  one 
instance  in  which  the  entire  face,  including  both  auricles,  was 
involved. 


19$  CUTANEOUS   DISEASES   OF   THE    AURICLE. 

A  mistake  in  diagnosis  is  practically  impossible,  although 
to  a  certain  extent  the  disease  resembles  eczema.  In  the  lat- 
ter affection  the  intense  pruritus,  the  presence  of  some  local 
exciting  cause,  the  brighter  color  of  the  affected  part,  and 
the  moist  surface,  together  with  the  more  rapid  progress, 
will  usuallv  render  a  differential  diagnosis  easy. 

Treatment. — Locally  we  mav  employ  yigorous  friction 
with  a  strong  alkaline  soap  to  relieye  the  infiltration,  after 
which  an  astringent  or  soothing  ointment  may  be  applied. 
Another  plan  is  to  employ  counter-irritation  in  the  form  of 
tincture  of  iodine.  An  ointment  containing  either  iodine  and 
iodide  of.  potassium  or  pyrogallic  acid  in  the  strength  of  from 
one  to  four  per  cent  is  also  yaluable. 

In  the  seyere  cases,  the  galyano-cautery,  the  curette,  or 
eyen  the  knife  may  be  employed,  although  as  a  rule  these 
yigorous  measures  are  not  followed  by  satisfactory  results. 

Lupus  Vulgaris. —  Dermatological  literature  teaches  us 
that  this  is  one  of  the  rarer  cutaneous  affections,  and  its  loca- 
tion in  the  external  ear  is  still  more  unusual.  In  the  early 
stages  we  find  upon  some  portion  of  the  auricle  one  or  more 
small  hard  nodules  which  cause  a  slisfht  sensation  of  itching^ ; 
the  efforts  of  the  patient  to  relieye  this  abrade  the  surface  of 
the  eleyation,  which  soon  becomes  coyered  with  a  brownish 
crust.  As  the  disease  adyances  the  infiltrated  areas  increase 
in  size  and  number.  Those  which  appear  subsequently  un- 
dergo the  same  changes  already  described  as  characteristic 
of  the  original  deposit. 

The  progress  of  the  affection  is  slow  but  steady.  The  ero- 
sion of  the  surface  gradually  becomes  deeper  and  constitutes 
a  true  ulceration,  the  areas  of  local  necrosis  being  almost  im- 
mediately coyered  by  brownish  crusts  which  do  not  separate 
spontaneously.  When  the  crusts  are  remoyed  artificially  the 
ulcer  appears  but  slightly  depressed,  its  margins  are  poorly 
defined,  there  is  no  areola,  its  boundaries  merging  impercep- 
tibly into  the  normal  integument.  Still  later  there  seems  to 
be  an  effort  at  spontaneous  cicatrization,  which  results  in  con- 
siderable deformity  due  to  a  shrinking  of  the  cicatrix.  The 
affection  does  not  cease  spontaneously,  and  will  almost  surely 
inyolye  the  entire  auricle  unless  checked  by  local  measures. 

Treatment. — When  first  seen,  it  is  our  duty  to  remoye  the 
inyolvcd  area  as  completely  as  "possible,  proyidcd  the  disease 
is  in  its  earliest  stage  and  limited  in  extent.     In  many  cases 


LUPUS   VULGARIS— TREATMENT.  199 

the  complete  exxision  of  the  infiltrated  portion  of  the  auricle 
is  the  simplest  and  best  measure.  Another  method  is  to  thor- 
oughly curette  awav  the  deposit  with  a  sharp  spoon,  care 
being  taken  that  the  healthy  tissue  immediately  surrounding 
tiie  deposit  is  encroached  upon.  The  curettement  should  be 
followed  by  the  application  of  some  chemical  agent,  lactic  acid 
being  probably  the  best.  This  should  be  used  in  concentrated 
solution,  and  should  be  thoroughly  rubbed  into  the  tissues. 
From  the  fact  that  the  canal,  and  even  the  middle  car,  may  be 
attacked  if  the  progress  in  the  auricle  is  not  checked,  the 
surgeon  is  fully  justified  in  excising  the  entire  auricle  if  this 
is  so  infiltrated  as  to  permit  of  no  other  means  of  eradicating 
the  disease. 


CHAPTER    VIII. 


INFLAMMATORY   AFFECTIONS   OF   THE    AURICLE. 


Perichondritis. — We  have  ahead v  describee]  an  inflamma- 
torv  condition  of  the  cartikii^inous  traniework  of  the  external 
ear  following  an  injury  to  the  part.  Occasionally  such  a  con- 
dition is  met  with  as  an  idiopathic  affection,  or  is  a  complica- 
tion of  an  acute  inflammation  of  the  external  auditory  meatus. 
The  particular  part  of  the  auricle  affected  will  depend  largely 
upon  the  locality  occupied  by  the  inflammatory  process  in  the 

external  auditory  meatus,  the  dis- 
ease spreading  bv  contiguity  of 
structure,  when  depending  upon 
such  a  cause. 

The  symptoms  to  which  the 
disease  gives  rise  are  a  feeling  of 
heat  in  the  external  ear,  quickly 
followed  by  severe  pain.  The 
auricle  soon  begins  to  increase 
in  size,  while  over  the  affected 
area  the  skin  is  of  a  bright-red 
hue,  due  to  an  increased  arterial 
vascularity.  As  the  disease  ad- 
vances the  pant  becomes  more 
and  more  swollen,  and  the  nor- 
mal outline  of  the  auricle  entire- 
ly disappears.  This  is  due  to  an 
effusion  of  fluid  between  the  car- 
tilage and  perichondrium,  dis- 
secting this  last  named  structure 
from  the  underlying  cartilage.  The  fluid  is  at  first  serous, 
but  quickly  becomes  purulent.  The  deformity  varies  con- 
siderably, according  to  the  particular  area  involved.  Where 
the  inflammatory  condition  \vithin  the  meatus  involves  the 
anterior  wall,  the  tragus  alone  is  the  part  usually  affected, 

(*oo) 


Fig.  71. — Deformity  following  peri- 
chomlrilis. 


PERICHONDRITIS— ERYSIPELAS- ABSCESS.  201 

while  if  the  circumscribed  inllanimatorv  process  is  situated 
upon  the  posterior  or  superior  walls  of  the  canal,  the  peri- 
chondritis is  apt  to  be  extensive,  and  is  accompanied  by 
marked  deformity.  If  unrelieved  by  therapeutic  measures 
the  fluid  is  evacuated  spontaneously.  In  such  an  event 
several  sinuses  appear  either  upon  the  anterior  or  posterior 
surface  of  the  pinna,  and  close  spontaneously  only  after  a 
prolonged  period.  A  high  degree  of  deformitv  is  the  usual 
result  in  those  cases  which  are  allowed  to  progress  without 
surgical  interference  (Fig.  71). 

Treatment. — The  treatment  of  the  condition  is  identical 
with  that  advocated  in  considering  perichondritis  due  to 
traumatic  causes,  with  the  cxcej)tion  that  aspiration  of  the 
tluid  is  not  admissible,  since  its  purulent  character  precludes 
the  possibilitv  of  a  favorable  result,  in  the  severe  cases 
the  j>rocedure  advocated  bv  Ciruening  *  of  "  through-and- 
ihrough  "  drainage  is  probablv  the  most  advisable  j)lan 
of  treatment.  This  consists  in  thoroughlv  opening  the  ab- 
scess bv  means  of  incisions  which  pass  comi)letely  through 
the  substance  of  the  auricle  from  the  anterior  to  the  pos- 
terior surface,  strips  of  iodoform  gauze  being  subsequently 
passed  through  the  openings  thus  made.  In  a  case  under  the 
care  of  the  author  the  tragus  was  the  j)art  involved,  and  a 
rapid  cure  followed  free  incision,  with  a  thorough  curetting 
of  the  cavitv. 

Erysipelas. — This  affection  occurs  as  a  comj)licati(jn  of 
facial  ervsipelas.  and  requires  no  special  consideration  either 
as  regards  the  clinical  course  which  it  runs,  or  the  treatment 
to  be  instituted  for  its  relief. 

Abscess. — An  abscess  of  the  auricle  involving  its  cartilagi- 
nous portion  constitutes  in  realitv  a  perichondritis,  a  con- 
dition which  has  already  been  described  in  detail.  Occasion- 
ally we  meet  with  a  localized  collection  of  pus  in  that  portion 
of  the  auricle  consisting  of  fibrous  and  fattv  tissue — the  lobule. 
Most  frequently  the  affection  depends  upon  a  local  infection, 
either  from  an  earring  or  following  the  oj)cration  of  piercing 
the  ears.  Evacuation  of  the  abscess  by  incision  is  followed 
by  com[)lcte  and  rapid  recovcrv. 

Occasionallv  we  find  a  superficial  abscess  in  other  portions 
of  the  auricle,  the  cartilaginous  framework  being  uninvolved  ; 

*  Archives  of  Otology,  vol.  xix,  p.  22. 


202      INFLAMMATORY    AFFECTIONS    OF    THE    AURICLE. 


these  constitute  really  retention  cysts,  and  are  caused  by  the 
blocking  up  of  the  orifice  of  a  sebaceous  follicle  with  sub- 
sequent disintegration  of  the  retained  secretion.  In  the  early 
stages,  when  the  condition  is  one  of  retention  only,  removal 
of  the  obstruction  is  all  that  is  necessary.  After  decomposi- 
tion has  taken  place,  however,  the  proper  procedure  is  to  in- 
cise the  tumor  freely,  after  which  the  lining  membrane  is  to 
be  dissected  out  or  thoroughly  curetted,  to  prevent  recur- 
rence. 

Othaematoma  (Fig.  72). — A  transudation  of  sanguineous 
fluid  beneath  the  perichondrium  is  frequently  met  with  as  the 
result  of  an  injury.     Occurring,  however,  without  the  history 

of  traumatism,  the  origin  of  the 
condition  has  been  a  matter  of  no 
little  speculation.  While  hcema- 
toma  auris  is  frequently  met  with 
among  the  insane,  numerous  au- 
thentic reports  are  found  in  which 
the  affection  has  occurred  sponta- 
neously, in  persons  of  perfectly 
sound  mind.  Age  seems  to  exert 
but  little  causative  influence,  Weil  * 
having  reported  a  case  occurring 
at  the  age  of  fifteen  months. 

The  condition  is  present  usu- 
ally upon  one  side  only,  although 
in  a  case  reported  by  Brunnerf 
its  occurrence  upon  one  side  was 
followed,  a  year  later,  by  a  similar 
condition  in  the  opposite  organ. 
From  the  fact  that  it  has  been  frcquentlv  observed  among 
the  insane  it  is  possible  that  some  intracranial  lesion  may  be 
responsible  for  its  occurrence.  The  investigations  of  Brown- 
Sequard :{;  would  add  weight  to  this  view,  since  they  show 
that  section  of  the  restiform  bodies  in  dogs  will  produce  the 
local  lesion  in  question.  It  is  quite  probable  that  in  many 
cases  an  injury  which  has  been  entirely  forgotten  is  the  real 
cause  of  the   pathological  condition.     Flesch  **  believes  that 


Fig.  72. — Othaematoma. 


*  Monatsschrift  fiir  Ohrenheilkunde,  1883,  No.  3. 
•f-  Archiv  fiir  Ohrenheilkunde,  vol.  v,  26. 

J  Canstatter  Jahresbericht,  1869,  vol.  ii,  p.  27. 

*  Archiv  fiir  Ohrenheilkunde,  vol.  xx,  p.  291. 


OTH>EMATOMA— TREATMENT.  203 

certain  variations  in  the  structure  of  the  auricular  cartilages 
predispose  to  the  extravasation  of  blood,  but  advances  no 
theory  as  to  the  cause  of  the  anomalous  structure  of  the  car- 
tilage. It  can  only  be  said,  therefore,  that  the  a;tiological 
factor  in  a  proportion  of  the  cases  is  still  unsolved. 

The  affection  consists  essentially  in  an  effusion  of  blood, 
which  separates  the  perichondrium  from  the  cartilage.  Oc- 
casionally we  find,  on  examining  the  walls  of  the  cavity,  that 
small  plates  of  cartilage  have  been  forcibly  torn  from  the 
framework  of  the  auricle  during  the  process  of  extravasation. 
The  tumefaction  appears,  as  a  rule,  somewhat  suddenly.  It 
may  be  preceded  by  a  feeling  of  burning  or  pruritus,  but  usu- 
ally there  are  no  prodromal  symptoms.  The  anterior  surface 
of  the  auricle  is  usually  involved  to  a  greater  or  less  extent, 
and  the  obliteration  of  the  normal  outline  is  correspondingly 
complete.  The  integument  covering  the  tumor  is  either 
normal  in  color  or,  if  the  effusic^n  is  large  in  amoimt,  may  ap- 
pear pale  on  account  of  the  pressure. 

After  its  appearance,  the  effusion  mav  disapj)tar  spon- 
taneously, or  it  mav  be  evacuated  bv  si)ontaneous  rupture, 
or  the  contents  of  the  cyst  may  suppurate.  Absorption  is  so 
uncommon  that  we  should  never  wait  for  its  occurrence, 
while  it  is  probable  that  traumatism  is  resjxjnsible  for  the 
spontaneous  evacuation  of  the  fluid  in  most  cases,  whether 
this  occurs  with  or  without  sujijniration. 

Treatment. — The  treatment  varies  according  to  the  size 
of  the  tumor  and  nature  of  its  contents,  whether  this  consists 
of  blood  alone  or  whether  purulent  infection  has  already  oc- 
curred. 

When  there  are  evidences  of  pus  formation  free  evacua- 
tion should  be  at  once  resorted  to,  the  case  being  treated  as 
one  of  simple  perichondritis. 

Where  the  tumor  is  small  and  of  recent  occurrence,  simple 
pressure  by  means  of  a  compress  held  firmly  in  place  by  a 
roller  bandage  should  first  be  tried.  This  method,  combined 
with  systematic  massage  of  the  auricle,  is  valuable  in  man}'^ 
instances.  In  tumors  of  large  size  resort  may  be  had  to 
aspiration,  followed  by  the  compress,  bandage,  and  massage. 
Where  the  effusion  is  of  such  proportions  as  to  cause  consid- 
erable tension  of  the  overlying  tissues,  evacuation  by  free 
incision  is  the  most  advisable  procedure,  the  cavity  being 
afterward  thoroughly  curetted  to  remove  all  necrotic  tissue 


Z04 


INFLAMMATORY   AFFECTIONS   OF   THE    AURICLE. 


and  to  favor  a  rapid  obliteration  of  the  space  bv  granulation 
and  adhesion.  After  thus  thoroughly  removing  the  contents 
of  the  cyst  the  wound  should  be  packed  firmlv  with  iodoform 
gauze,  and  subsequently  managed  according  to  the  rules  of 
general  surgerv. 

It  should  always  be  remembered  that  in  the  severe  cases 
considerable  deformity  of  the  auricle  ma}-  follow,  and  the 
patient  should  be  warned  accordingh'. 

Thickening  of  the  Lobule. — This  condition  consists  of  a 
hypertrophy  both  of  the  connective  tissue  forming  the  frame- 
work of  the  lobule  and  of  the  glandular  structures  of  the  re- 
gion, as  the  result  of  a  chronic  inflammatory  process.  The 
most  frequent  cause  of  the  affection  is  mechanical  irritation, 
occasioned  by  the  wearing  of  a  ring  in  the  ear,  the  margins 
of  the  artificial  opening  through  which  this  is  passed  instead 
of  cicatrizing  and  becoming  covered  with  normal  epithelium 
remaining  denuded,  and  thus  afford  an  avenue  for  the  entrance 
of  infectious  germs.  Some  metals  are  easily  acted  upon  bv 
moist  air,  and  are  particularly  prone  to  cause  such  a  condi- 
tion, the  products  of  their  oxidation  destroying  the  newly 
formed  epithelial  cells  and  leading  to  the  result  above  given. 
When  this  process  has  continued  for  some  length  of  time  the 
pendent  portion  of  the  auricle  becomes  elongated,  thickened, 
tender  to  the  touch,  and  in  soiuc  cases  the  seat  of  spontaneous 
jiain.  The  chief  annoyance  to  which  it  gives  rise,  however, 
is  the  deformity.  Occasionally  the  lodgment  of  more  virulent 
bacteria  upon  this  denuded  surface  produces  small  abscesses. 

Treatment. — The  treatment  of  the  condition  is  simple, 
and  consists  first  in  the  removal  of  the  local  cause.  If  the 
deformity  has  reached  a  high  degree  a  plastic  operation  may 
become  necessary  for  the  removal  of  the  superabundant  tissue. 

Ossification. — Curiously  enough,  this  condition  is  exceed- 
ingly rare,  although  several  instances  have  been  mentioned  in 
otological  literature.  The  causes  which  may  be  considered 
to  be  active  in  its  production  seem  to  be  malnutrition,  severe 
local  inflammation,  or  some  profound  disturbance  of  the  cir- 
culation of  the  part,  such  as  exposure  to  intense  cold.  When 
osseous  tissue  has  once  been  deposited,  the  recognition  of 
the  affection  is  exceedingly  simple.  The  auricle  becomes 
stiff,  inflexible,  and  boardlike  to  the  touch.  The  ossification 
may  be  limited  either  to  a  small  area  or  mav  involve  a  con- 
siderable portion  of  the  organ. 


OSSIFICATION— GANGRENE.  205 

In  a  case  reported  by  Linsmavcr  *  the  bony  deposit  ex- 
tended into  the  floor  of  the  canal.  The  helix,  scaphoid  fossa, 
and  antihelix  are  the  regions  most  frequently  afTccted,  and  the 
condition  may  be  present  upon  one  or  both  sides.  Relief  is 
demanded  both  on  z^ccount  of  the  deformity  and  also  because 
of  the  pain  which  any  pressure  upon  the  rigid  oigan  causes, 
as  when  the  patient  attempts  to  lie  upon  the  affected  side. 

Treatment. — The  treatment  consists  in  a  remoyal  of  the 
abnormal  deposit  where  this  is  of  limited  extent.  Where  a 
large  part  of  the  auricle  is  inyolyed  amputation  of  the  entire 
organ  is  justifiable. 

Gangrene. — Complete  necrosis  of  the  tissues  making  up 
the  iraniew(jrk  and  coverings  of  the  external  ear  is  occasion- 
ally met  with  in  cases  which  have  not  been  subjected  to  any 
severe  traumatism.  A  marked  general  cachectic  condition, 
following  an  acute  illness  which  has  lowered  the  vitality  of 
the  patient  greatly,  or  such  as  may  be  occasioned  by  some 
prolonged  suppurative  process  accompanied  by  bony  necro- 
sis, frequently  acts  as  a  predisposing  cause.  If  we  combine 
with  such  a  condition  slight  but  continuous  pressure  upon 
the  auricle,  as  might  occur  in  a  patient  confined  to  bed  for  a 
long  period  and  lying  upon  one  side  for  a  considerable  inter- 
val of  time,  the  pressure  might  be  sutlicient  to  determine  the 
process  under  consideration. 

Treatment. — The  treatment  is  sufficiently  indicated  by 
the  causes  oj^erative  in  j)r()ducing  the  alTecticjn.  Suj)porting 
and  stimulating  measures  arc  to  be  adopted  for  the  removal 
of  the  predisposing  cause,  while  care  is  to  be  taken  to  prevent 
any  pressure  ujjon  the  auricle,  bearing  in  mind  the  ease  with 
which  local  nutritive  processes  are  interfered  with  when  the 
general  tone  of  the  body  is  greatly  lowered.  If  the  process 
has  already  developed  we  should  attempt,  by  means  of  warm 
applications,  to  restore  the  circulation  of  the  region  to  its 
normal  state,  and  at  the  same  time  to  favor  spontaneous 
separation  of  the  necrotic  tissue  if  local  necrosis  has  occurred. 
Where  the  necrosis  is  but  superficial,  the  application  of 
strong  chemical  caustics  may  hasten  repair,  the  local  irrita- 
tion exciting  a  reactive  inflammation  which  in  itself  becomes 
a  valuable  therapeutic  measure,  causing  the  early  exfoliation 
of  the  slough  and  the  development  of  healthy  granulations. 


*  Wien.  Klin.  Woch.,  1889,  No.  12. 


CHAPTER    IX. 


BEXI(;X   TUMORS   OF   THE   ALRICT.E. 

Fibroma. — A  fibroid  tumor  is  one  of  the  most  common  of 
the  beni2;n  neoplasms  which  is  met  with  upon  the  auricle. 
The  lobule  is  the  part  usually  involved.  The  negro  race  -is 
especiallv  liable  to  the  affection,  and  among-  this  people  the 
growths  frequentlv  attain  a  large  size.  Local  irritation  at- 
tendant upon  wearing 
/     ./  ^^    ,.        .  ornaments  in  the  ear  is 

the  most  common  ex- 
citing ^etiological  factor. 
Although  the  lobule  is 
the  part  most  frequentlv 
affected,  the  concha  is 
occasionallv  the  site  of 
a  growth  of  this  charac- 
ter, and  in  a  case  report- 
ed by  Ilabermann*  the 
external  meatus  was  par- 
tially occluded  by  the 
tumor,  which  sprang 
from  the  concha. 

Upon  phvsical  exam- 
ination the  tumor  pre- 
sents a  hard  surface, 
which  is  usuallv  smooth, 
but  occasionally  nodu- 
lar. Microscopicallv  the 
mass  is  made  up  of  dense,  white,  fibrous  connective  tissue. 
In  a  case  reported  bv  Anton  +  (Fig.  y})  the  growth  was  a 
soft  fibroma  and  contained  nianv  connective-tissue  cells  in- 
terspersed between  the  fibres. 


Fig.  73. — Soft  fibroma  filling  the  concha. 
(Anton.) 


*  Archiv  fiir  Ohrenheilkunde,  vol.  xviii,  p.  76. 
f  Ibid.,  vol.  xxviii,  p.  2S5. 
(206) 


FIBROMA— LIPOMA— ATHEROMA.  207 

These  growths  are  of  especial  interest  on  account  of  the 
fact  that  thev  frequently  recur  after  removal,  the  recurrent 
tumors  occasionally  assuming  a  malignant  tvpe,  especially 
after  repeated  operations  of  excision  have  been  instituted. 

Treatment. — The  operative  treatment  is  simi)le.  The  mass 
is  to  be  circumscribed  with  the  knife,  the  incision  extending 
through  the  entire  thickness  of  the  affected  part  and  Iving 
completely  outside  of  it,  within  healthv  tissue.  After  the  neo- 
])lasm  has  been  extirpated  the  edges  of  the  wound  are  to  be 
brought  together  by  sutures,  and  the  parts  dressed  according 
to  general  surgical  rules.    Recovery  is  usually  uninterrupted. 

Where  the  tumor  involves  the  lobule  the  incision  should 
be  so  located  as  to  effect  the  removal  of  redundant  tissue  and 
enable  the  parts,  upon  replacement,  to  be  molded  into  a  form 
symmetrical  with  that  of  the  lobule  of  the  opposite  side. 

In  addition  to  puie  fibromata,  tumors  are  occasionally  met 
with  which  are  made  up  of  a  mixture  of  fibrous  tissue  with 
myxomatous,  cartilaginous,  or  other  elements.  In  a  case  re- 
ported by  Haug  *  the  growth  was  Ivmphangio-fibroma. 

Lipoma. — A  true  fattv  tumor  has,  so  far  as  I  know,  never 
been  found  upon  the  auricle  itself.  Thev  are  (jccasionally  met 
with,  however,  in  its  immediate  vicinitv,  usuallv  just  beh^w 
the  lobule.  Kipp  +  has  re{)orted  a  case  of  fibro-lipoma  of  the 
concha,  the  microscope  showing  the  presence  of  cavernous 
tissue  as  well. 

Atheroma  (Figs.  74  and  751. — A  tumor  of  this  character 
results  from  blocking  up  of  the  sebaceous  follicles  with  which 
the  integument  covering  the  external  ear  is  suj)plicd.  The 
secretion  which  the  glands  produce  is  imjirisoned  by  the  ste- 
nosis of  the  orifices  of  the  ducts,  dilates  the  gland  cavitv.  and 
gives  rise  to  a  tumefaction  of  varving  size.  Where  the  gland 
is  active,  the  rapid  formation  of  its  product  may  produce  so 
much  pressure  as  to  cause  spontaneous  rui)ture.  On  the 
other  hand,  after  attaining  a  certain  size  the  obstruction  in 
the  duct  mav  be  overcome,  allowing  a  suflficient  amount  of 
the  contents  to  escape  to  relieve  the  tension  without  restor- 
ing the  normal  patency  of  the  tube.  This  process  may  be 
repeated  indefinitely,  and  the  patient  presents  with  the  his- 
tory of  a   recurrent  discharge  from  the  growth  at  varying 


*  Archiv  fiir  Ohrenheilkunde,  vol.  xxxii,  p.  161. 

■}•  Transactions  of  the  American  Otological  Society,  vol.  iii,  part  iii. 


208 


BENIGN   TUMORS   OF   THE    AURICLE. 


intervals.     Again,  the  pressure  may  be  so  severe  as  to  excite 
an  inflammation  within  the  sac,  witli  the  consequent  produc- 
tion of  a  purulent  discharge. 

The  lobule  is  a  favorite  seat  for  these 
growths,  or  the  junction  of  the  lobule  with 
the  skin  of  the  neck.  Marian  *  has  re- 
ported a  case  in  which  the  neoplasm  filled 
the  concha.  Where  spontaneous  evacua- 
tion has  not  taken  place  dissection  usually 
reveals  a  distinct  sac.  Where  the  con- 
tents of  the  cyst  have  undergone  infection 
and  rupture  has  occurred  as  the  result  of 
an  inflammatory  process,  the  lining  mem- 
brane is  usually  so  amalgamated  with  the 
surrounding  tissues 
as  to  render  its  rec- 
ognition as  a  dis- 
tinct structure  dif- 
ficult. 

Under  the  mi- 
croscope the  con- 
tents of  such  a  tu- 
mor is  found  to  be  made  up  of  seba- 
ceous material,  degenerated  epithelial 
cells,  with  an  occasional  admixture  of 
cholesterin  crystals. 

Treatment. — This  condition  is  best 
combated  by  surgical  interference. 
This  consists  in  the  removal  of  the 
growth.  An  incision  is  made  through 
the  overlving  integument,  and  the  tu-    Fi...  75.— Sebaceous  tumor  of 

■  ,,     ,  ^,  ,  ,  the  lobule.     (Claiborne.) 

mor  IS  shelled  out  from  the  envelope 

withotit  rupture  of  tiie  sac.  In  this  wav  a  possible  recur- 
rence is  giiarded  against.  Such  a  procedure,  however,  is 
frequentlr  impossible,  the  sac  being  oj)cncd  and  its  contents 
being  evacuated  in  spite  of  the  greatest  care.  In  this  event 
the  entire  sac  should  be  completely  dissected  out  from  the 
structures  with  which  it  has  become  amalgamated.  It  is  well 
after  making  such  a  dissection  to  thorotighly  curette  the  cav- 
ity by  means  of  a  sharp  spoon,  in  order  that  every  vestige 


Fig.  74. — .\lheronia. 


Archiv  fiir  Ohrenhcilkunde,  vol.  xxv,  p.  66. 


ATHEROMA— TREATMENT— ANGIOMA. 


209 


of  the  ciivclopiiii^  membrane  may  be  removed.  Where  the 
mass  is  of  but  small  dimensions  and  spontaneous  discharge 
has  taken  place,  a  thorough  curetting  of  the  sac,  followed  by 
the  application  of  a  strong  solution  of  nitrate  of  silver,  may 
cause  complete  obliteration  of  the  cavitv  and  prevent  a  re- 
currence. 

Angioma. — A  neoplasm  of  this  character  is  seldom  met 
with  in  the  external  ear,  and  the  reported  cases  have  varied 
greatly  both  in  the  area  involved  by  the  neoplasm  and  in  the 
degree  U)  which  the  vascular  abnormitv  has  developed.  In 
a  case  reported  by  Chimani  *  the  condition  was  one  of  cirsoid 
aneurism  which  was  present  upon  the  left  side  of  the  head  at 
birth,  and  subsecpiently  extended  until  a  large  portion  of  the 
auricle  was  involved,  j)articularlv  the  posterior  aspect  of  the 
organ.  The  external  ear  was  displaced  outward,  and  was  of 
a  dark  purplish-red  color;  a  distinct  murmur  was  perce{)tible 
over  the  growth.  The  condition  improved  sc^newhat  under 
injections  of  perchloride  of  iron,  although  recurrence  took 
place  at  a  subsequent  period.  The  mass  was  completely  dis- 
sipated by  a  repetition  of  the  same  treatment. 

Occasionally  an  exposure  to  cold,  as  in  Kipp's  f  case,  seems 
to  be  responsible  for  the  affection,  although  in  many  instances 
they  are  congenital,  differing  only  in  degree  from  the  com- 
mon birthmark  or  port-wine  stain. 

Although  we  do  not  consider  the  condition  as  perilous  to 
life,  Jungken;}:  has  reported  an  instance  in  which  luvmorrhage 
from  the  growth  terminated  fatally. 

Treatment. — We  arc  usually  consulted  on  account  of  tiie 
deformit\  which  these  growths  cause,  and  the  measures  for 
their  relief  must  depend  upon  their  size  and  character,  and 
the  coincident  presence  of  a  similar  condition  upon  some 
(Jther  portion  (^f  the  face.  When  involving  only  the  integu- 
ment and  consisting  of  a  small  stain,  repeated  applications  of 
the  galvano-cautery  usually  obliterate  the  abnormitv.  Where 
the  mass  is  of  large  size  and  the  vessels  are  more  fully  devel- 
oped, complete  excision  is  the  best  procedure.  This  may  be 
effected  by  seizing  the  base  of  the  mass  with  a  clamp  and  re- 
moving it  /;/  iofo,  ligating  the  stump  in  several  portions.  In 
other  instances  the  clamp  may  be  dispensed  with,  and  the 

*  Archiv  fiir  Ohrenheilkunde,  vol.  viii,  p.  63. 
■f  Transactions  of  the  American  Otological  Society,  Jul)',  1885. 
J  Schwarlze,  Ohrenheilkunde,  p.  77. 
15 


210  BENIGN   TUMORS   OF   THE    AURICLE. 

mass  dissected  out,  the  vessels  being  divided  between  two 
ligatures,  thus  preventing  excessive  haemorrhage  during  the 
operation.  The  employment  of  the  ligature  to  cause  the 
growth  to  slough  away  slowly  is  scarcely  advisable. 

Injections  of  fluids  for  the  purpose  of  coagulating  the  con- 
tents of  the  tumor  are  not  free  from  danger,  since  by  the  dis- 
lodgment  of  a  clot,  embolism  of  important  vessels  may  fol- 
low, or  general  sepsis  may  result. 

The  emplovment  of  the  galvano-cautery  knife  or  loop  for 
the  excision  of  such  a  neoplasm  should  only  be  undertaken  if 
a  clamp  is  used,  and  even  if  the  mass  were  removed  in  this 
manner  most  would  prefer  to  ligate  the  pedicle  in  several  por- 
tions rather  than  to  trust  to  a  closure  of  the  vessels  by  the 
action  of  the  incandescent  blade  or  wire. 

Where  the  tumor  increases  rapidly  in  size  at  the  site  of  its 
first  appearance  and  other  areas  of  the  integument  become 
involved  in  regions  entirely  distinct  from  the  original  location, 
we  have  to  deal  not  only  with  the  lesion  as  it  appears  upon 
the  external  ear,  but  by  our  measures  for  the  relief  of  this,  we 
should  aim  to  prevent  a  similar  condition  from  developing 
subsequently  in  neighboring  regions.  This  can  onlv  be  ef- 
fected, I  think,  by  shutting  off  the  arterial  supply  of  the  entire 
region  by  the  ligation  of  the  trunk  from  which  the  various 
vessels  spring.  After  such  an  operation  the  dilated  vessels 
will  in  many  instances  be  obliterated,  while  those  remaining 
will  be  much  diminished  in  size,  and  any  remaining  angioma- 
tous masses  can  be  treated  upon  the  rules  already  laid 
down. 

It  should  be  remembered  that  the  vessels  upon  one  side  of 
the  face  anastomose  freely  with  those  upon  the  opposite  side, 
and  less  radical  measures  than  those  given  above  may  not 
be  sufficient  to  obliterate  the  condition. 

Cystoma  (Fig.  "jG). — It  is  still  a  matter  of  discussion  as  to 
what  particular  form  of  neoplasm  this  term  should  be  applied. 
Many  use  it  to  designate  a  localized  tumefaction  upon  the 
auricle  due  to  a  circumscribed  collection  of  fluid  not  de- 
pendent upon  traumatism.  Many  again  apply  to  similar  con- 
ditions the  term  hasmatoma  or  perichondritis,  although  there 
may  be  no  evidence  of  a  sanguineous  effusion  or  of  an  inflam- 
matory process,  and  although  the  history  may  reveal  no  ade- 
quate cause  for  the  occurrence  of  either  affection.  The  for- 
mer view  seems  to  me  the  more  tenable  and  is  advocated 


CYSTOMA. 


21  I 


bv  Ilartmann,*  whn  applies  the  name  of  cvst  of  the  auricle  to 
tumors  of  this  description.     This  opinion  is  supported  by  the 
appearance  of  the  interior  of   the  sac,  upon    incision  of  the 
tumor.      There  is  no  evidence  of 
any  inflammation  of  the  perichon- 
drium ;     there    are    no    fibrinous 
clots,  nor  anv  other  evidence  of  a 
previous  traumatism.     The  devel- 
opment seems  to  depend  upon  an 
effusion  of  serum  simplv.    Exposed 
cartilage,  however,  is  occasionally 
found  within  the  cvst. 

These  tumors  make  their  ap- 
|)earance,  as  a  rule,  upon  the  an- 
terior surface  of  the  auricle,  which 
they  involve  more  or  less  com- 
j)letely.  The  overly  ing  integu- 
ment is  normal  in  color  and  not 
tender  to  the  touch.  The  tume- 
laction  aj)pears  quite  suddenlv. 
and  shows  little  or  no  tcndencv  to 

increase  in  size,  relief  being  demanded  simjtlv  on  account  of 
the  deformity.  Harsh  manipulation  or  contusion  of  the  part 
may  cause  an  inflammation  of  the  cartilage,  but  this  condition 
is  superadded,  and  not  a  part  of  the  original  {)rocess. 

The  cause  of  the  affection  is  naturally  hypothetical.  It 
may  possibly  be  due  to  a  degeneration  in  the  cartilagiiu^us 
framework  of  the  auricle,  somewhat  similar  to  that  which 
causes  the  spontaneous  develo|)ment  of  a  ha:matoma  auris. 

Treatment. — The  treatment  consists  in  repeated  aspira- 
tion ui  the  fluid  or  of  evacuation  bv  incision,  after  which 
the  cavity  is  obliterated  by  packing  the  wound  with  gauze. 
Fischenischf  has  obtained  good  results  bv  massage  in  these 
cases.  Manipulation  in  C(jnjunction  with  aspiration  is  cer- 
tainly worthy  of  trial.  After  evacuation  of  the  contents  of  the 
cyst  in  this  manner  the  walls  should  be  kept  in  contact  1)\ 
means  of  a  j^roperly  constructed  clamp  or  bv  a  firm  bandage. 

Certainly  the  surest  method  of  treating  these  cases  is  by 
incision.     This  should  be  made  in  one  of  the  natural  folds  so 


Fig.  76. — Cystom.a  of  auricle. 


*  Zeitschrift  fiir  Ohrenheilkunde,  vol.  xv,  p.  156,  and  vol.  xvii,  p.  232. 
f  Archiv  fur  Ohrenheilkunde,  vol.  xxv,  p.  299. 


212  BENIGN    TUMORS   OF   THE    AURICLE. 

as  to  prevent  deformity.  After  the  sac  has  been  thoroughly 
cleansed  by  irrigation,  the  margins  of  the  incision  may  be 
sutured,  a  few  strands  of  horsehair  being  passed  through  the 
sac  to  act  as  a  drain.  By  this  method  a  slight  irregularity 
may  remain  at  the  upper  and  lower  extremities  of  the  incision 
at  the  points  of  entrance  and  exit  of  the  horsehair  drain.  To 
avoid  this,  the  entire  wound  upon  the  anterior  surface  may 
be  sutured,  and  drainage  secured  by  puncturing  the  cartilage 
so  as  to  make  an  opening  upon  the  posterior  surface  of  the 
auricle.  By  securing  drainage  through  this  channel,  and 
allowing  the  incision  upon  the  anterior  surface  to  unite  bv 
first  intention,  the  probability  of  recurrence  is  reduced  and 
all  dcformitv  avoided. 

Papilloma. — Simple  papillomata  are  found  upon  the  auricle 
only  in  the  form  of  warts.  Two  instances  of  anomalous  devel- 
opments in  the  epidermal  layer  have  been  reported,  which 
might  properly  be  classed  under  this  term.  These  were  ob- 
served by  Buck,  *  and  consisted  of  a  dense,  hornlike  pro- 
tuberance springing  from  the  outer  and  posterior  portion  of 
the  helix,  in  one  of  these  the  excrescence  attained  a  length 
of  three  fourths  of  an  inch,  while  the  base  was  nearly  as 
broad.  Its  growth  had  undoubtedly  been  favored  by  harsh 
methods  of  treatment.  The  mass  was  removed,  and  complete 
recovery  followed. 

*  Manual  of  Diseases  of  the  Ear,  New  York,  iSSg,  pp.  52,  53. 


CHAPTER   X. 

MALIGNANT   TUMORS   OF   THE   AURICLE    AND    OF   THE   MEATUS. 

It  is  comparatively  seldom  that  the  external  ear  is  the 
primary  seat  of  a  malisj^nant  neoplasm,  although  the  condition 
is  occasionally  met  with.  Any  portion  of  the  external  ear 
may  be  the  site  of  the  primary  deposit,  from  which  situation 
the  neoplasm  may  spread  in  any  direction  until  a  lar^re  area  is 
involved.  In  some  instances  the  trrowth  orij^inates  in  the  ex- 
ternal auditory  meatus,  the  auricle  bein«^  attacked  subsequent- 
ly, or  the  reverse  may  be  true,  the  growth  appearing  first 
upon  the  pinna  and  extending  into  the  auditorv  meatus. 

Malignant  neoj)lasms  of  the  dccj)er  portions  of  the  ear  or 
mastoid  process  are  still  more  infrequentiv  nut  with.  The 
most  common  malignant  growth  which  affects  the  region  in 
question  is  cj)illiclioma,  sarcoma  being  of  rare  cjccurrence. 

Epithelioma. — The  same  causes  operative  upon  other  por- 
tions of  the  bodv  in  the  j)r(Kluction  of  malignant  growths,  act 
here  to  produce  the  condition.  In  a  number  of  instances  per- 
sistent mechanical  irritation  has  seemed  to  be  the  most  prom- 
inent causative  factor.  In  these  cases  a  slight  abrasion  of  the 
external  ear  subsequentlv  becomes  the  seat  of  a  malignant 
ulceration  on  account  of  the  persistent  efiforts  of  the  patient  to 
relieve  the  local  discomfort  to  which  it  gives  rise.  Individuals 
under  the  age  of  fifty  are  seldom  attacked,  although  in  one 
instance  a  malignant  growth  developed  at  the  age  of  nineteen. 

The  progress  of  these  tumors  is  usually  slower  than  in  the 
other  regions  of  the  bodv,  several  years  being  required  for 
them  to  reach  any  considerable  size.  Secondary  enlargement 
of  the  cervical  glands  is  not  ordinarily  present,  and  for  this 
reason  the  prognosis  in  malignant  disease  of  the  auricle  is 
relatively  better  than  that  of  a  similar  condition  in  other 
portions  of  the  body.  Even  where  glandular  infiltration  has 
occurred  there  seems  to  have  been  little  tendencv  to  sys- 
temic infection,  and  removal  of  the  original  mass  and  of  the 
affected   lymphatics  has  been,  in  the  majority  of  cases.  efTec- 

(213) 


214  MALIGNANT   TUMORS   OF  THE   AURICLE   AND   MEATUS. 

tual  in  curing  the  disease.  That  systemic  infection  is  so 
slight  in  cancer  of  the  external  ear  is  probably  due  to  the 
fact  that  the  infectious  material  is  absorbed  from  cartilaginous 
tissue  very  slowly,  and  that  the  local  lesion  develops  to  such 
an  extent  that  it  demands  removal  before  extensive  glandular 
infiltration  has  taken  place. 

The  physical  characteristics  are  almost  unmistakable.  No 
ulceration  resembles  in  appearance  that  presented  by  an  epi- 
thelioma. Before  ulceration  has  taken  place  it  may  be  im- 
possible to  decide  the  character  of  the  neoplasm,  although 
from  the  fact  that  it  docs  not  resemble  any  of  the  benign 
growths  found  here,  diagnosis  by  exclusion  is  simple. 

After  the  superficial  tissues  have  broken  down  the  eroded 
surface  appears  reddened,  moist,  irregular  in  outline,  and  some- 
what raised  above  the  healthy  integument  surrounding  it. 
It  bleeds  easily  on  touch,  and  is  frecjuently  tender.  Interfer- 
ence \yith  the  nutritive  supply  of  the  cartilage  causes  this 
to  become  necrotic,  and  with  the  process  of  exfoliation  inflam- 
matory reaction  occurs.  Such  a  condition  is  characterized 
by  the  presence  of  exuberant  granulations  the  same  as  in  a 
simple  perichondritis,  and  during  this  stage  an  errop  in  diag- 
nosis may  occasionally  be  made.  The  true  character  of  the 
tumor  can  be  made  out  by  removing  a  small  portion  and  sub- 
mitting it  to  a  microscopical  examination.  The  removal  of  a 
small  fragment  is  easily  accomplished  by  means  of  the  cold 
wire  snare,  and  this  aid  to  diagnosis  should  always  be  em- 
ployed before  a  positive  opinion  is  given.  On  account  of  the 
occurrence  of  exuberant  granulation  tissue,  microscopical  evi- 
dence of  a  negative  character  does  not  exclude  malignant  dis- 
ease, although  positive  cyidence  settles  the  question  beyond 
a  doui)t. 

Treatment. — The  results  of  treatment  are  unusually  favor- 
able. If  the  mass  is  removed  by  radical  measures  there  seems 
to  be  slight  tendency  to  a  recurrence.  Lymphatic  infiltration 
should  be  dealt  with  at  the  same  time,  and  it  is  only  in  ad- 
vanced cases  that  a  fairly  favorable  prognosis  is  unwarrant- 
able. The  treatment  should  be  the  same  as  that  of  maligtiant 
neoplasms  in  any  portion  of  the  body,  earl}'  removal  by  the 
knife  being  the  only  safe  procedure.  Care  should  be  taken 
that  every  vestige  of  the  growth  is  excised,  the  incision  pass- 
ing beyond  the  limits  of  infiltration  and  lying  in  perfectly 
healthy  tissue.     The  exact  plan  to  follow  will  vary  with  the 


EPITHELIOMA— TREATMENT.  21  5 

different  cases.  If  the  auricle  alone  is  involved,  and  the  in- 
hltration  is  extensive,  it  is  best  to  amputate  the  pinna  at  once. 
If  possible,  when  this  is  done  care  should  be  taken  to  pre- 
serve enough  of  the  integument  about  the  orifice  of  the 
meatus  to  permit  of  its  being  sutured  to  the  skin  of  the  face, 
thus  securing  a  patulous  external  canal  lined  with  epidermis. 
Where,  however,  the  growth  has  extended  ever  so  slightly 
into  the  canal,  the  auricle  and  the  entire  cartilaginous  meatus 
should  be  removed.  When  this  is  necessary  it  is  almost  hope- 
less to  attempt  to  secure  a  patent  external  meatus,  although 
the  effort  should  be  made.  For  this  purpose  a  drainage  tube, 
either  of  soft  rubber,  silver,  or  aluminium,  should  be  kept  con- 
stantly in  the  canal  in  order  to  preserve  its  lumen.  Such  a 
device  may  be  worn  for  a  long  period,  and  be  rem(n-ed  once 
daily  for  the  purpose  of  cleansing  the  passage,  being  quickly 
replaced  to  prevent  the  occlusion  of  the  canal  by  the  granu- 
ha'um  tissue.  Even  after  such  a  tube  has  been  worn  many 
months  the  attempt  frequently  fails.  It  may  be  possible  in 
some  instances  to  employ  skin  grafting,  either  by  Thiersch's 
method  or  by  twisting  a  small  flap  from  the  adjoining  region 
into  the  orifice  of  the  canal,  and  thus  secure  a  proper  tegumen- 
tary  lining.  I  have  tried  neither  of  these  methods,  since  the 
procedure  was  not  suited  to  the  two  cases  which  came  under 
my  observation.  In  one  instance,  where  the  growth  involved 
the  posterior  wall  (jf  the  canal,  the  meatus  was  ccjmpletclv  ob- 
literated in  spite  of  persistent  efforts  to  maintain  its  patency. 
In  a  second  case  a  perfectly  patent  canal  was  obtained  by 
uniting  the  integument  of  the  anterior  wall  of  the  passage 
with  the  margin  of  the  cutaneous  incision  through  the  ^kin  of 
the  face,  the  cutis  being  dissected  uj)  for  a  considerable  dis- 
tance to  permit  disjtlacement  toward  the  meatus.  Coaptation 
of  the  edges  was  not  attained,  and  this  does  not  seem  to  be 
necessary.  The  sutures  may  cut  through  at  the  end  of  a  few 
hours  and  still  perform  a  very  important  function,  the  parts 
being  held  in  position  for  a  sufficient  length  of  time  to  become 
so  firmly  fixed  by  plastic  effusion  as  not  to  retract  to  any  ex- 
tent after  the  sutures  have  given  way.  In  the  instance  named, 
a  considerable  portion  of  the  wound  healed  by  granulation, 
and  there  was  scarcely  any  deformity,  and  but  slight  con- 
traction at  the  entrance  of  the  meatus. 

In  excising  a  growth  of  this  character  involving  a  large 
portion  of  the  auricle,  a  little  care  will  enable  the  operator  to 


2i6  MALIGNANT  TUMORS  OF  THE   AURICLE   AND   MEATUS. 

replace  the  parts  in  such  a  manner  as  to  prevent  disfigure- 
ment. Where  the  parotid  gland  is  involved,  it  is  seldom  wise 
to  attempt  extirpation,  although  in  a  robust  patient  it  is  per- 
missible. As  the  facial  nerve  passes  through  this  large  glan- 
dular mass,  it  is  well  to  warn  the  patient  of  the  possibilitv  of 
facial  paralysis  following  the  operation. 

No  special  suggestions  are  necessary  concerning  the 
course  to  be  pursued  with  the  lymphatic  enlargements. 
These  are  dealt  with  on  general  surgical  principles.  The 
employment  of  the  galvano-cautery,  the  cold  snare,  chemical 
caustics,  etc.,  for  the  removal  or  the  destruction  of  a  malig- 
nant neoplasm  of  the  auricle  seems  to  the  author  scarcely 
justifiable,  although  manv  have  used  the  potential  cautery 
upon  small  growths  of  this  character,  with  eminently  satis- 
factory results. 

Sarcoma. — Occasionallv  a  sarcomatous  neoplasm  origi- 
nates primarily  in  the  external  ear,  or,  on  the  other  hand, 
this  organ  mav  be  involved  bv  contiguity  of  structure  from  a 
similar  growth  in  the  cervical  rcgi(jn.  The  growth  exhibits 
no  preference  for  any  j)articular  region,  any  part  of  the  exter- 
nal ear  being  equally  liable  to  inyolvement.  T'xtension  to  the 
external  auditory  meatus  has  occurred,  and  the  possibility  of 
this  should  always  be  borne  in  mind.  Such  an  extension  to  the 
canal  renders  extirpation  of  the  growth  less  easy  and  the  pos- 
sibility of  its  occurrence  constitutes  a  plea  for  early  operation. 

The  tumor  varies  in  appearance  according  to  its  situation, 
and  differs  from  an  epithelioma  in  that  ulceration  of  the  sur- 
face does  not  take  place  until  a  comparatively  late  period. 
The  mass  is  less  firm  than  an  epitheliomatous  tumor,  is  usu- 
ally more  vascular,  the  surface  being  frequently  traversed  by 
tortuous  blood  vessels.  The  tumor  may  grow  slowly  and 
exist  for  many  years  without  giving  rise  to  symptoms  suffi- 
ciently urgent  to  demand  operative  treatment  ;  on  the  other 
hand,  these  tumors  sometimes  increase  rapidly  in  size  and 
demand  interference  at  an  early  period. 

Treatment. — The  successful  treatment  depends  upon  the 
complete  removal  of  the  growth,  and  in  these  cases,  owing  to 
the  increased  vascularity  of  the  mass,  it  may  be  wise  to  cm- 
ploy  the  cold  or  incandescent  6craseur  or  the  galvano-cautery 
knife.  If  the  mass- is  completely  removed  at  the  point  of  pri- 
mary deposit,  recurrence  seldom  occurs.  Systemic  infection 
is  rare. 


//.    DISEASES   OE   THE  EXTERXAL   AUDITORY 

ME  A  TUS. 

Diseases  of  the  external  auditory  canal  nuiv  be  divided 
int(3  two  classes  as  rci:^ards  their  causation,  duration,  and 
extent. 

As  regards  causation,  either  primary  or  secondary. 

As  rcii^ards  duration,  either  acute  or  chronic. 

As  rcc,rards  extent,  either  circumscribed  or  dilTuse. 

While  intlammatory  chanjj^es  in  this  reg^ion  are  often  sec- 
ondary to  some  coexistini:;^  c«)ndition  of  the  tvmi)anum,  either 
circumscribed  or  diffuse  inflammation  may  occur  as  an  idio- 
pathic disease  both  in  the  acute  and  chronic  form. 


CllAI'Il  K    XI. 

CIRCl'.MSCKir.ED    EXTERNAI     OTITtS. 

A(  I  Ti:  Circumscribed  External  Onus. 

Olitis  fxtcma  cifiumscripla  acuta.     lurunclt. 

i^tiolog:y.— The  occurrence  of  a  circumscribed  inflamma- 
tion w  iihin  the  auditory  canal  is  usually  due  either  to  mechan- 
ical irritation,  the  result  of  scratching  the  ear  with  the  finger 
or  with  some  blunt  or  sharp  instrument;  to  inoculation  in  the 
same  manner;  to  a  loss  of  superficial  epithelium  as  a  result 
of  some  cutaneous  disease,  the  abraded  surface  forming  the 
point  of  entrance  for  pathological  bacteria;  or,  where  the  tym- 
panum is  the  seat  of  a  purulent  inflammation,  the  local  infec- 
tion may  take  place  through  the  ducts  of  the  glands  with 
which  the  meatus  is  supplied. 

It  is  doubtful,  probably,  whether  all  cases  are  not  the 
result  of  some  local  infection,  but  certain  constitutional  con- 
ditions predispose  strongly  to  the  disease  under  considera- 
tion.    The  local   lesion   sometimes  appears  without  any  dis- 

(217) 


2i8  CIRCUMSCRIBED   EXTERNAL   OTITIS. 

cernible  source  of  local  infection — in  other  words,  it  occurs 
as  an  idiopathic  disease.  Marked  impairment  of  the  general 
health,  disturbance  of  the  digestive  system,  anemia,  and  dia- 
betes render  an  individual  particularly  susceptible  to  the 
maladv. 

Pathology. — From  the  anatomical  structure  of  the  meatus, 
it  follows  that  as  the  external  or  fibro-cartilaginous  portion 
is  freely  sujiplied  with  glands,  this  is  the  part  most  usually 
attacked.  The  inferior,  posterior,  and  superior  walls  are 
more  frequently  affected  than  is  the  anterior.  Usually  the 
focus  of  the  inflammation  is  situated  near  the  oritice  of  the 
meatus,  although  it  may  be  located  in  any  pt)rtion  of  the 
canal,  and  occasionallv  is  met  with  in  the  osseous  part.  The 
abscesses  occur  usually  in  groups  rather  than  singly,  due  to 
the  fact,  probably,  that  infectious  material  from  the  same 
source  has  inoculated  several  glands  simultaneously.  The 
disappearance  of  one  "  crop "  is  apt  to  be  followed  by  an- 
other, thus  prolonging  the  course  of  the  affection.  This  is 
especially  true  where  any  diathetic  condition  is  present. 

Loewenberg*  lays  great  stress  upon  the  fact  that  certain 
micro-organisms  are  found  in  the  pus  discharged  from  these 
small  abscesses.  Schimmclbusch,+  working  in  the  same  line, 
likewise  attributes  the  local  abscess  to  the  presence  of  a  ba- 
cillus, but  has  shown  that  an  abrasion  of  the  normal  epithe- 
lium is  necessary  in  order  that  the  germ  may  develop  at  any 
point.  It  has  alreadv  been  stated  that  an  asthenic  constitu- 
tional condition  in  many  cases  predisposes  to  the  formation 
of  these  abscesses,  the  power  of  resistance  to  anv  morbid  pro- 
cess under  these  circumstances  being  much  reduced.  There 
is  considerable  evidence  to  show  that  a  trophic  disturbance 
caused  by  some  obscure  condition  in  the  nerve  trunks  which 
supply  the  meatus  may  also  be  the  prominent  causative 
factor. 

Urbantschitsch  ^  has  reported  instances  where  a  derange- 
ment of  the  trophic  nerves  of  one  side,  due  to  a  local  lesion, 
was  followed  very  quicklv  by  the  development  of  a  furuncle 
in  that  portion  of  the  canal  of  the  opposite  side,  supplied  by 
the   corresponding   nerve.     I    myself   have    seen    two   cases 


*  Dcutsch.  Med.  Woch.,  iS88,  No.  28. 

■)•  Arch,  fiir  Ohrenheilk.,  vol.  xxvii,  p.  252. 

^  Lehrb.  der  Ohrenheilk.,  Vienna,  1890,  p.  107  ;  Arch,  fiir  Oiiren.,  vol.  xxxv,  p.  5. 


rATHOLOGV— SYMPTOMATOLOGY 


219 


whicli  were  uiuloubtetlly  ol  a  reflex  truplio-neurotic  character. 
One  occurred  in  a  boy,  aj^ed  htteen.  wlio  suffered  from  a 
severe  traumatic  external  t)titis,  llie  abscess  beiui^  located  on 
the  posterior  wall  ol  the  canal.  Notwithstanding^  the  fact 
that  the  patient  was  in  excellent  general  condition,  the  oppo- 
site canal,  which  was  apparently  healthy  up  to  this  time,  was 
similarlv  alTected  about  four  days  after  the  incision  of  the 
hrst  abscess.  The  identity  in  the  location  of  the  abscess 
upon  either  side  and  the  absence  of  anv  other  exciting  cause, 
seemed  to  place  this  second  furuncle  in  the  category  under 
discussion.  In  the  second  case  the  development  of  a  small, 
circumscribed  area  of  inflammation  upon  the  floor  of  the 
right  meatus  was  followed  within  tuentv-four  hours  by  an 
exactly  similar  condition  in  the  same  location  upon  the  oppo- 
site sitle.  In  this  short  interval  the  local  process  had  reached 
maturitN'.  and  when  the  patient  was  seen  the  sectjiid  abscess 
was  discharging,  although  the  region  hail  l)ecn  inspected  with 
great  care  less  than  twcntv-four  hours  |)reviously.  and  was, 
at  that  time,  in  a  perfectly  normal  condition. 

We  must  believe,  therefore,  that  the  cause  may  be  reflex 
in  character  even  in  cases  where  the  general  health  is  unim- 
paired. After  infection  has  taken  place,  the  inflammatory  pro- 
cess advances  rapidly,  the  central  portion  of  the  affected  area 
losing  its  vitality  and  being  discharged  either  in  the  form  of 
pus  or  sometimes  as  a  distinct  mass  ol  necrotic  tissue.  Ordi- 
narily the  inflammation  does  not  extend  deeply  by  contiguity 
of  structure,  but  when  very  severe  the  underlying  tissues 
may  become  affected,  developing  a  perichondritis  of  the  canal 
or  auricle.  This  is  particularly  aj)t  to  take  place  when  the 
furuncle  is  located  on  the  anterior  wall,  the  entire  tragus  be- 
coming involved.  Excej)tionally,  the  affection  may  lead  to  a 
diffuse  external  otitis,  which,  Sj>reading  along  the  j)osterior 
wall  of  the  canal,  may  give  rise  to  periosteitis  of  the  osseous 
portion,  and  may  thus  bv  extension  involve  the  middle  ear 
itself.  In  either  event  extension  to  the  mastoid  cells  may 
occur. 

Symptomatology. — The  first  svmjitoms  with  which  the  dis- 
ease is  ushered  in  is  usually  a  feeling  of  fullness  or  discomfort 
in  the  ear.  or  sometimes  a  slight  itching  sensation,  causing  the 
patient  to  press  the  finger  against  the  tragus.  Soon,  how- 
ever, he  finds  that  this  part  is  tender  upon  pressure,  and 
a  little  later  spontaneous  pain  in  the  ear  becomes  very  well 


220  CIRCUMSCRIBED   EXTERNAL   OTITIS. 

marked.  At  this  juncture  the  hearing  becomes  considerably 
interfered  with,  owing  to  the  stenosis  of  the  meatus  resulting 
from  the  tumefaction.  For  the  same  reason  there  is  fre- 
quently tinnitus,  usually  rather  high  pitched  in  character, 
which  increases  as  the  affection  progresses.  This  may  be 
due  either  to  stenosis  of  the  canal  or  to  the  congestion  of  the 
deeper  structures  from  the  increased  blood  supply.  The 
pain  increases  in  severity,  so  that  within  twenty-four  hours 
from  the  first  feelings  of  discomfort  it  may  be  almost  un- 
bearable, while  the  ear  continues  to  be  very  tender  to  the 
touch,  especially  w-hen  pressure  is  exerted  in  front  of  the  tra- 
gus. From  the  intimate  relation  between  the  cartilage  of  the 
tragus  and  the  intermaxillary  articulation  the  motions  of  the 
lower  jaw  are  interfered  with,  and  mastication  frequently  be- 
comes so  painful  that  the  patient  can  take  liquid  food  only. 
The  spontaneous  pain  is  especially  severe  at  night  and  fre- 
quently may  prevent  sleep,  although  during  the  day  the  pa- 
tient may  be  able  to  follow  his  vocation.  If  the  abscess  is 
located  upon  the  anterior  wall  of  the  canal  the  parts  in  front 
of  the  ear  appear  swollen  and  slightly  turgescent.  If,  on  the 
contrary,  the  posterior  wall  of  the  canal  is  affected,  one  of  the 
frequent  symptoms  noticed  is  an  undue  prominence  of  the 
auricle,  the  external  ear  being  crowded  somewhat  forward 
and  standing  out  more  prominently  from  the  side  of  the  head 
than  does  its  fellow  on  the  opposite  side.  When  the  furuncle 
is  in  this  location,  also,  the  slightest  pressure  upon  any  por- 
tion of  the  pinna  causes  intense  suffering.  When  the  abscess 
is  situated  upon  the  posterior  wall,  a  not  infrequent  symptom, 
and  one  to  which  the  patient  is  apt  to  attach  undue  gravity, 
is  a  marked  oedema  of  the  integument  behind  the  ear. 

Infiltration  of  the  cervical  glands,  and  also  of  the  pre-au- 
ricular  glands,  is  of  common  occurrence,  tiie  former  giving 
rise  to  a  hard,  irregular  swelling  extending  from  just  below 
tiie  lobule  downward  along  the  course  of  the  stcrno-mastoid 
muscle  to  the  angle  of  the  jaw,  while  in  the  latter  case  the 
side  of  the  face  immediately  in  front  of  the  ear  presents  some 
irregular  induration  due  to  an  inflammation  of  the  lymjihatic 
nodules  in  this  region.  The  parotid  gland  itself  mav  also  par- 
ticipate in  this  inflammatory  process,  causing  its  outline  to 
become  distinctly  defined  both  to  ocular  inspection  and  to 
palpation.  This  is  due  to  secondary  engorgement  of  the 
gland,  and  consequently  suppurative  inflammation  of  the  paro- 


DIAGNOSIS. 


221 


tid  occasionally  complicates  a  circumscribed  cxtenial  otitis. 
Occasionally  we  find  directly  behind  the  auricle,  a  rather 
prominent  i^roup  of  small  lymphatic  <;lands ;  when  these  are 
present  a  localized  infiammation  upon  the  posterit)r  wall  of 
the  canal  is  attended  by  considerable  infiltration  of  these 
structures,  in  which  case  the  (vdema  before  spoken  of  is  re- 
l)laced  by  an  irregular  induration  which  is  so  poorly  defined 
in  its  limitations,  that  it  may  be  mistaken  for  an  inllammatory 
condition  of  the  mastoid  periosteum. 

Constitutional  symptoms  are,  as  a  rule,  not  well  marked. 
The  attack  may  run  its  course  in  an  adult  with  scarcely  any 
elevation  of  temperature,  or  the  temperature  may  be  sli<rhtly 
elevated— reaching^  perhaps  99°  or  100°.  If  n^landular  inflam- 
mation is  present  as  a  secondary  affection,  the  temperature  is 
more  apt  to  be  elevated  than  when  this  does  not  exist.  A  feel- 
inc^  of  general  malaise,  headache,  loss  of  appetite,  etc.,  is  attrib- 
utable rather  to  the  loss  of  sleep  and  the  discomfort  attendant 
uj)on  the  condition  within  the  canal  than  to  any  actual  systemic 
infection.  After  these  symptoms  have  persisted  for  from  forty- 
eight  hours  to  three  or  four  days,  they  disappear  quite  sud- 
denly, and  coincident  with  their  cessation  a  purulent  discharge 
appears  in  the  meatus.  This,  it  need  scarcely  be  stated,  is  due 
to  the  spontanetnis  ru|>ture  of  the  abscess,  the  discharge  of  its 
contents  causing  an  abatement  of  all  the  distressing  manifes- 
tations. 

As  stated  under  Pathology,  however,  these  abscesses  ordi- 
narily appear  in  groups,  so  that  in  the  course  of  a  few  days 
the  symptoms  already  narrated  are  repeated.  If  the  inflam- 
matory process  extends  to  the  tympanum  or  to  the  mastoid 
cells,  the  pain  becomes  more  intense  and  the  constitutional 
symptoms  also  are  more  marked.  The  temperature  rises,  the 
pain  instead  of  being  localized  involves  the  entire  temporal 
region,  or  may  manifest  itself  as  a  severe  general  headache. 
The  impairment  in  hearing  and  the  subjective  disturbances 
become  more  marked,  and  the  gravity  of  the  affection  is  evi- 
denced by  the  increased  prostration  from  which  the  patient 
suffers. 

Diagnosis.  —  It  would  seem  that  the  diagnosis  of  such  an 
affection  would  present  no  difficulties,  but  this  is  frequently 
by  no  means  simple.  In  the  early  stages  the  patient  is  not 
able  to  localize  the  pain,  but  complains  simply  of  a  feeling  of 
discomfort  and  heaviness  in  the  head,  and  may  even  ignore 


CIRCUMSCRIBED   EXTERNAL   OTITIS. 


the  ear  entirely  and  refer  all  the  painful  sensations  to  the  pres- 
ence of  carious  teeth.  An  inspection  of  the  ear  at  this  period 
may  reveal  absolutely  nothing.  If,  however,  we  supplement 
ocular  inspection  b}'  carefuUv  testing  the  sensitiveness  of  the 
walls  of  the  canal  by  means  of  a  cotton-tipped  probe,  usually 
some  one  point  will  be  found  where  pressure  causes  the  pa- 
tient to  wince  slightly.  Too  much  stress  can  not  be  laid,  how- 
ever,  upon  the  necessity  of  first  inspecting  the  ear  without  the 
use  of  the  speculum,  the  auricle  being  drawn  upward  and 
backward,  or  in  a  very  young  child  downward  and  backward, 
and  the  entrance  of  the  meatus  first  examined  by  reflected 
light  before  the  introduction  of  any  instrument.  It  is  well, 
also,  to  press  gentlv  upon  the  posterior,  inferior,  superior,  and 
anterior  walls  of  the  canal  with  the  cotton-tipped  probe  before 
introducing  the  speculum,  in  order  to  recognize  any  tender 
point  which  might  escape  detection  after  the  insertion  of  the 
instrument.  \'crv  frequently,  at  an  carlv  stage,  this  tender- 
ness may  be  the  onlv  evidence  suggestive  of  the  local  lesion, 
if  this  examination  is  made  before  the  speculum  is  inserted, 
a  very  slight  tumefaction  may  be  observed  encroaching  upon 
the  lumen  of  the  canal,  from  one  of  its  walls.  This  area  may 
not  differ  in  color  from  the  surrounding  parts,  or  it  may  be 

of  a  slightly  pinkish  or  red- 
dish hue.  This  alteration 
in  color  is  seldom  notice- 
able, and  the  insertion  of  the 
speculum  may  entirely  ob- 
literate the  local  swelling. 
The  deeper  parts  should  be 
tested,  after  the  speculum 
has  been  introduced,  by 
means  of  the  probe  in  the 
manner  already  described, 
and  the  presence  of  one  or 
more  tender  points  be 
looked  upon  with  suspicion. 
If  the  local  process  is  more 
advanced  the  areas  of  tume- 
faction are  easily  recognized 
(Fig.  yy);  if  the  inflammatory  process  is  located  near  the 
orifice  of  the  canal,  the  introduction  of  the  speculum  may  be 
painful.      As   many  patients,  however,   wince   slightly  upon 


Fio.  77. —  Otitis  externa  acuta  circumscripta, 
at  the  entrance  of  the  canal  involving  the 
superior  and  posterior  walls,  (Natural 
size.) 


DIAGNOSIS. 


the  introduction  of  anv  instrument  into  the  meatus,  this  sijj^n 
should  be  accepted  with  considerable  caution.  As  has  been 
stated,  circumscribed  inflammation  of  the  canal  is  usually 
located  in  the  movable  portion,  and  although  occasionally 
occurring  in  the  osseous  segment,  anv  localized  tumefaction 
in  this  region  should  be  looked  upon  with  great  suspicion, 
especially  if  situated  upon  the  superior  posterior  wall,  since 
in  this  locality  the  mastoid  antrum  is  separated  from  the 
meatus  bv  a  comparatively  thin  plate  of  bone,  and  an  inHam- 
niation  within  the  mastoid  cells  often  causes  an  encroachment 
upon  the  lumen  of  the  canal  in  this  localitv.  When  this  is 
the  condition  otoscopic  ex- 
amination gives  the  impres- 
sion of  a  canal  w  Inch  rapid- 
ly becomes  narrow  at  the 
fundus,  the  line  of  demar- 
cation between  the  drum 
membrane  and  the  sui)erior 
and  posterior  walls  of  the 
meatus  being  poorly  de- 
fined. In  some  instances 
only  a  small  slitlike  open- 
ing is  visible  at  the  inner 
extremity  of  the  canal,  the 
membrana  tympani  being 
com{)lctcly  hidtlen  from 
view  except  over  this  area 
(Fig.  78).     Such  a  condition 

means,  almost  invariably,  a  collection  of  tluid  within  the  mas- 
toid antrum,  and  always  indicates  an  affection  of  the  deeper 
structures,  although  the  j)r()cess  may  have  had  its  origin  in 
the  external  meatus  :  in  other  words,  the  affection  is  no  longer 
confined  to  the  meatus,  but  involves  the  middle  ear.  On  the 
contrary,  in  furuncular  inflammaticMi  the  greatest  narrowing 
is  at  the  orifice  of  the  meatus,  and  if  the  speculum  can  once 
be  carried  past  this  obstruction,  which  lies  comparatively 
near  the  external  opening  of  the  canal,  an  unobstructed  view 
can  be  obtained  of  the  j)arts  that  lie  beyond.  Where  a  cir- 
cumscribed external  otitis  occurs  in  an  ear  which  is  already 
the  seat  of  a  purulent  inflammation  of  the  tympanum,  the 
location  of  the  tumefaction  in  the  superficial  meatus  will  fre- 
quently enable  us  to  distinguish   between  a  simple  circum- 


Fio.  78. — Otitis  cxtcnia  acuta  of  the  <lecp 
jwrtion  of  the  meatus,  indicative  of  in- 
flammation of  the  mastoid.  (Natural 
size.) 


224 


CIRCUMSCRIBED   EXTERNAL   OTITIS. 


scribed  external  otitis  and  one  due  to  an  inflammation  of  the 
mastoid  process  (compare  Figs,  "jj  and  78). 

External  manipulation  will  reveal  considerable  tenderness 
upon  pressure  in  front  of  the  tragus  if  the  anterior  wall  is  af- 
fected ;  indeed,  as  the  entire  fibro-cartilaginous  portion  of  the 
canal  is  moved,  to  a  certain  extent,  by  any  pressure  in  this 
region,  this  test  in  adults  is  of  great  importance  in  making  the 
differential  diagnosis  between  inflammatory  affections  of  the 
meatus  as  distinguished  from  those  of  deeper  parts — that  is,  of 
the  middle  ear  or  of  the  mastoid  process.  In  the  same  way 
if  the  auricle  be  grasped  firmly  and  moved  in  various  direc- 
tions, any  inflammation  in  the  canal  will  be  evidenced  by  the 
pain  which  this  manipulation  causes.  It  is  also  well  to  exert 
pressure  upon  the  walls  of  the  canal  from  below  upward  and 
from  above  downward,  and  from  behind  forward  successively, 
if  the  cartilaginous  meatus  is  affected  it  will  be  scarcely  pos- 
sible not  to  elicit  some  tenderness,  no  matter  where  the  ab- 
scess is  located.  The  occurrence  of  oedema  over  the  mastoid 
process  may  lead  to  the  erroneous  supposition  that  the  osseous 
structures  have  become  involved.  This  mistake  need  never 
be  made  if  care  is  taken  to  test  for  the  presence  of  tenderness 
over  the  mastoid  process  itself,  without  communicating  any 
motion  to  the  auricle  in  applying  the  pressure.  To  do  this 
the  fingers  of  the  hand  are  rested  lightly  upon  the  side  of  the 
head,  while  the  thumb  is  pressed  firmly  over  the  cvdcmatous 
area,  taking  care  that  this  pressure  shall  be  exerted  just  be- 
hind the  line  of  insertion  of  the  auricle,  and  in  a  direction 
backward  and  inward  rather  than  forward  and  inward.  In 
this  way  the  movable  portion  of  the  canal  is  in  no  way  dis- 
turbed and  the  pressure  is  brought  to  bear  directly  upon  the 
mastoid  process.  It  will  be  found  that  where  the  inflamma- 
tion is  confined  to  the  canal  alone  no  tenderness  is  elicited  by 
this  manipulation,  although  the  thumb  may  sink  quite  deeply 
into  the  ocdematous  tissues  and  leave  its  imprint  there  when 
removed.  As  soon,  however,  as  the  pressure  is  directed  in 
the  slightest  degree  forward,  so  as  to  move  either  the  auricle 
or  the  fibro-cartilaginous  canal,  the  patient  gives  evidence  of 
intense  suffering.  Although  simple  in  execution  this  point  is 
of  great  value,  especiallv  in  differential  diagnosis.  In  the 
same  manner  a  careful  examination  of  the  glandular  infiltra- 
tion, either  beiiind  the  ear  or  below  it,  will  usually  enable 
one  to  recognize  its  nature  in  distinction  from  a  mastoid  ]ieri- 


PROGNOSIS. 


'■~S 


osteitis,  or  an  extravasation  of  pus  due  to  the  spontaneous 
evacuation  of  th.e  mastoid  abscess  beneath  the  sterno-niastoid 
muscle  throut;h  the  diagastric  fossa.  In  some  instances,  how- 
ever, it  will  be  necessary  to  observe  the  condition  for  several 
days  before  an  exact  opinion  can  be  arrived  at. 

A  suppurative  intlammation  of  the  parotid  gland  mav  oc- 
casionally lead  to  error.  This  condition,  from  the  local  ten- 
derness, the  severe  pain  upon  masticatit)n,  and  the  local  tu- 
mefaction of  the  anteroinferior  wall  of  the  canal  just  within 
the  orifice  of  the  meatus,  may  sometimes  be  mistaken  for  a 
furuncle  ;  especially  is  this  the  case  when  we  remember  that 
we  frequently  find  the  parotid  enlarged  secondarily  as  the 
result  of  the  circumscribed  external  otitis  located  here.  Prac- 
tically such  an  error  would  be  a  matter  of  no  significance, 
since  the  treatment  would  be  the  same.  Uj)on  evacuation  of 
the  abscess,  either  spontaneouslv  or  bv  incision,  the  (piantitv 
of  |)us  discharged  wnuld  readily  siiow  wliether  we  had  to 
deal  with  simple  localized  inllammation  of  the  canal,  or  with 
a  breaking  down  of  the  substance  of  the  jiarotid,  in  wliicii  tiie 
j)us  had  made  its  wav  in  the  surface  in  this  situ.ilion. 

Prognosis. —  When  uncomplicated,  the  affection  ordinarilv 
runs  its  couise  in  from  four  to  eight  davs,  the  svmptoms 
being  at  their  height  about  the  third  dav.  Care  must  be  exer- 
cised in  expressing  an  opinion  upon  this  {)oint.  as  the  succes- 
sive infection  of  other  areas  mav  prolong  the  affection  consid- 
erablv.  The  general  health  of  the  |)atient  is  a  fact  of  great 
importance  in  considering  how  rapidlv  the  termination  of 
the  disease  mav  be  expected,  reinfection  being  much  more 
apt  to  take  place  if  the  general  condition  is  impaired.  Per- 
sonal cleanliness,  precise  attention  in  carrving  out  the  local 
measures  instituted  for  the  relief  of  the  condition,  and  the 
avoidance  of  anv  unnecessar\  handling  of  the  part — all  aid  in 
bringing  about  a  speedy  termination.  So  far  as  danger  to  life 
is  concerned,  this  is  usuallv  considered  almost  ;///.  It  should 
be  remembered,  however,  that  in  exceptional  instances  exten- 
sion takes  place  both  to  the  mastoid  cells  and  to  the  middle 
car,  and  that  death  has  resulted  from  meningitis  or  sinus 
thrombosis.  Occasionally  dehiscences  exist  in  the  walls  of 
the  osseous  meatus,  rendering  extension  to  the  intracranial 
structures  easv.  It  should  also  be  remembered  that  after 
the  contents  of  the  abscess  have  been  evacuated,  either  spon- 
taneously or  by  incision,  a  denuded  surface  remains,  through 
16 


226  CIRCUMSCRIBED    EXTERNAL   OTITIS. 

which  infection  may  easily  take  place.  The  author  has  seen 
one  instance  of  erysipelatous  infection  in  this  rci^ion,  resulting 
in  death. 

Treatment. — If  observed  early,  our  first  efforts  should  be 
directed  to  abort  the  attack,  if  possible,  and  thus  prevent  pus 
formation.  With  this  end  in  view,  the  local  abstraction  of 
blood  by  means  of  the  natural  leech,  or  better,  perhaps,  by  the 
wet  cup,  should  be  instituted  at  once.  If  the  area  in  front  of 
the  tragus  is  tender  the  blood  should  be  abstracted  from  this 
region.  In  an  adult  two  oinices  of  blood  may  be  taken  away 
if  the  wet  cup  is  used  ;  if  the  natural  leeches  are  preferred, 
two  or  three  may  be  applied  directly  in  front  of  the  tragus. 
When  the  posterior  or  superior  wall  is  the  site  of  the  inflam- 
mation the  best  results  are  obtained  by  abstracting  blood  from 
the  mastoid  region.  Owing  to  the  free  intercommunication 
of  blood  vessels  in  this  regicjn  it  is  usually  wise  to  take  away 
a  greater  quantity  here  than  when  the  leeches  are  applied 
in  front  of  the  tragus.  With  reference  to  the  relative  value 
of  the  wet  cup  and  the  natural  leech,  it  should  be  stated  that 
the  wet  cup  is  to  be  decidedly  preferred,  except  perhaps  in 
the  case  of  children  under  six  or  seven  years  of  age,  who  may 
object  less  forciblv  to  the  natural  leech  than  any  instrumental 
procedure.  If  the  natural  leech  is  used,  the  meatus  should 
be  occluded  with  cotton  to  prevent  the  animal  from  attach- 
ing itself  within  the  canal,  an  accident  which  has  occurred  in 
several  instances.  The  chief  objection  to  natural  leeches  is 
that  in  many  cases  they  are  difficult  to  applv,  and  the  precise 
quantitv  of  blood  taken  away  can  not  be  estimated.  The  re- 
sulting ha?morrhage  frequently  continues  for  a  considerable 
time  after  the  leeches  have  been  removed,  and  may  be  a  source 
of  annoyance  both  to  the  patient  and  his  friends.  Quite  a  num- 
ber of  instances  have  been  reported  in  which  erysipelas  has 
followed  their  application,  a  fact  which  ccrtainlv  constitutes 
a  grave  objection.  The  wet  cup,  on  the  contrarv.  affords  us 
a  means  of  taking  awav  the  exact  amount  of  blood  we  deem 
desirable;  it  can  be  easily  applied,  and.  if  carefullv  done,  its 
use  is  not  attended  bv  anv  more  than  trifling  momentary  pain. 
In  very  young  children  restraint  will  alwavs  be  necessary 
whichever  method  is  used,  while  adults  almost  invariably 
prefer  to  endure  the  momentarv  sufTcring  which  the  artificial 
leech  causes,  rather  than  to  subject  themselves  to  the  annov- 
ance  which  the  application  of  the  natural  leech  entails.     The 


TREATMENT— BLOODLETTING. 


227 


instrumental  abstraction  of  blood  niav  be  effected  by  the  use 
of  a  device  which  consists  of  a  glass  tube  closed  at  one  end, 
while  the  mari^in  of  the  open  extremity  is  ground  accurately 
to  permit  of  its  exact  application  to  the  integument.  The 
interior  of  the  tube  is  fitted  with  an  air-tight  piston,  the  rod 
of  which  is  provided  with  a  thread.  The  other  extremity  of 
the  tube  is  provided  with  a  cap  through  which  the  piston  rod 
passes.  Beyond  the  cap  the  piston  rod  is  provided  with  a 
nut  which  traverses  the  thread  upon  the  rod  ;  bv  turning  this 
nut  the  piston  is  made  to  travel  the  length  ot  the  tube. 

If  now  the  piston  is  lowered  as  much  as  possible,  and  the 
open  extremity  of  the  tube — previouslv  smeared  with  a  little 
vaseline — is  aj){)lied  closclv  to  the  skin,  successive  turns  of 
the  nut  will  exhaust  the  air  from  the  tube  and  cause  an  in- 
tense congestion  of  the  area  which  it  covers,  while  the  soft 
parts  will  bulge  into  the  tube  as  tlie  air  above  is  rarefied. 
and  the  pressure  of  the  air  witliDUt  will  be  suf^cientlv  great 
to  hcjld  the  aj)i)aratus  in  position.  Ihis  process  of  dry  cuj)- 
l)ing  may  of  itself  be  sufficient  in  certain  instances  to  relieve 
the  symptoms:  if,  however,  it  is  tlecided  to  abstract  a  certain 
quantity  of  blood,  the  cup  should  be  left  iti  jjosition  for  a 
few  minutes,  after  which  it  should  be  removed  and  the  local 
congested  area  punctureil  in  several  places,  either  bv  means 
of  a  small,  sharj)  knife  or  bv  a  scarificator,  shown  in   I-'ig.  79. 


In  either  case  the  process  is  not  painful,  as  the  turgescence  of 
the  parts  is  so  great  that  but  little  sensitiveness  remains.  The 
cup  should  now  be  cjuicklv  reapplied,  when  a  free  flow  of 
blood  foUcjws,  and  as  much  may  be  removed  as  seems  desira- 
ble. The  application  of  this  instrument  would  at  first  seem 
painful,  on  account  of  the  local  tenderness  in  the  immediate 
vicinity  of  the  ear;  it  should  be  remembered,  however,  that 
local  bloodletting  is  applicable  only  to  the  early  stages 
of  the  disease,  at  which  period  this  tenderness  is  not  well 
marked. 

In  place  of  the  instrument  mentioned  above,  the  author 
employs  one  in  which   the  scarification  is  performed  without 


CIRCUMSCRIBED   EXTERNAL   OTITIS. 


the  removal  of  the  cup,  while  the  ordinary  ear  syringe  is  used 
to  exhaust  the  air.  Fig,  80  shows  the  method  of  operation, 
and  renders  a  detailed  description  superfluous.  The  instru- 
ment is  so  constructed  as  to  be  interchangeable  with  the  tip 

of  the  ear  svringe, 
and  thus  the  neces- 
sity of  carrying  a 
cumbersome  appa- 
ratus is  avoided. 

As  before  stated, 
local  bloodletting  is 
of  value  in  aborting 
the  affection  only 
in  the  very  early 
stages.  When  the 
j)ain  has  lasted  for 
thirty-six  or  forty- 
eight  hours  before 
the  patient  is  seen 
for  the  first  time, 
this  procedure  will 
almost  always  be 
useless  as  a  prophy- 
lactic measure,  al- 
though it  may  tem- 
jiorarily  relieve  the 
pain  ;  usually,  how- 
ever, it  only  adds 
to  the  discomfort 
which  the  patient 
is  already  suffering. 
After  the  abstraction  of  a  certain  amount  of  blood  in  the 
very  early  stages,  the  local  application  of  cold  is  of  undoubt- 
ed benefit,  both  for  the  relief  of  pain  and  for  the  purpose  of 
aborting  the  attack.  When  the  focus  of  inflammation  is  lo- 
cated upon  the  posterior  wall  of  the  canal,  the  application 
of  cold  may  be  made  by  means  of  the  Leiter  coil,  shown  in 
Fig.  81,  the  coil  being  so  molded  that  it  applies  itself  closely 
to  the  surface  of  the  mastoid.  The  aural  ice  bag  shown  in 
Fig.  70  may  also  be  employed  for  the  same  purpose.  When 
the  focus  of  inflammation  is  situated  elsewhere,  the  coil  be- 
hind the  car  is  of  but  little  value,  and,  in  order  to  be  eflicient, 


Fig.  80. — Author's  artihcial  let-ch, 
adapted  to  the  ordinary-  hard- 
rubber  ear  syringe.  The  piston- 
rod  of  the  syringe  is  arranged 
with  a  bayonet  catch  to  hold  it  in 
position  when  it  is  withdrawn, 
thus  maintaining  the  vacuum. 


TREATMENT— COLD— INSTILLATIONS. 


22g 


such  an  apparatus  must  be  so  arranged  that  a  continuous 
stream  of  cold  water  i-^  made  to  pass  through  a  tube  bent  in 
the  form  of  the  letter  U,  and  of  such  dimensions  that  it  may 
be  inserted  into  the  auditory  meatus.  Thcorcticallv.  this  is 
tlie  ideal  method  of  treatment; 
practically,  it  is  of  little  value,  for 
when  the  meatus  is  inflamed  it  is 
so  tender  that  the  presence  of  such 
an  instrument  causes  considerable 
discomfort,  and  by  its  pressure 
aggravates  the  condition  it  is  in- 
tended to  relieve.  Where  the 
canal  is  large,  however,  the  meth- 
od mav  be  tried. 

The  instillation  of  fluid  j>repa- 
rations  to  relieve  the  pain  seems 
to  me  to  be  a  measure  of  practi- 
cally no  value  whatever.  A  glance 
over  the  literature  on  the  subject 
affords  sufficient  evidence  of  this, 
1  think,  on  account  of  the  large 
number  of  remedies  which  have 
been    advocated.     Thus    we    find 

recommended  solutions  of  morj)hinc,  atropine,  subacetate 
of  lead,  cocaine,  menthol,  oil  of  eucalvptus,  dilute  carbolic 
acid,  veratrine.  and,  in  fact,  all  the  drugs  of  the  j>harma- 
copa'ia  which  have  a  real  or  imagined  analgesic  local  action. 
It  must  be  remembered  that  the  absorption  of  any  remedy 
from  the  unbroken  skin  takes  place  verv  slowlv  and  produces, 
therefore,  when  a{)plied  to  the  cutis,  almost  no  effect  aside 
from  that  due  to  the  evaporation  of  the  li(|uid.  with  the  con- 
sequent production  of  a  certain  amount  of  cold.  The  small 
amount  of  benefit  to  be  derived  from  such  applications  is 
more  than  counterbalanced,  in  mv  opinion,  bv  the  sodden 
condition  of  the  ejiidcrmis,  which  is  produced  by  the  reten- 
tion of  the  liquid  in  the  canal,  making  subsequent  instru- 
mental manipulations  much  more  difficult,  and  masking  to  a 
very  great  degree  the  local  appearance  upon  speculum  ex- 
amination. 

No  remedies  should  be  emploved  locally  unless  the  epi- 
dermis has  already  been  exfoliated  over  a  considerable  sur- 
face, a  condition  with  which  we  not  unfrequently  meet  as  the 


Fic.  8i. —  The  Lcitcr  coil. 


230 


CIRCUMSCRIBED    EXTERNAL    OTITIS. 


result  (jf  a  previous  chronic  inflammation.  When  this  condi- 
tion is  present,  any  of  the  before-mentioned  drugs,  either 
singly  or  in  combination,  may  be  beneficial.  They  are  most 
conveniently  used  in  the  form  of  gelatin  bougies,  as  advocated 
by  Gruber*  under  the  name  of  amygdale  aurium.  They  con- 
sist essentially  of  small  conical  suppositories  of  gelatin,  the 
drug  being  incorporated  in  their  substance;  the  heat  of  the 
canal  dissolves  the  gelatin,  and  the  drug  is  thus  brought 
directly  into  contact  with  the  walls  of  the  canal  and  even 
distributed  over  the  inflamed  surface.  Previous  to  their  in- 
sertion the  canal  should  be  thoroughly  cleansed  with  a  mild 
antiseptic  solution,  after  which  the  suppository  is  inserted  and 
the  orifice  of  the  meatus  closed  by  a  small  pledget  of  cotton. 
This  method  is  certainly  preferable  to  the  use  of  oleaginous 
preparations,  and  mav  to  an  extent  relieve  the  pain  if  the 
superficial  epidermis  has  desquamated.  Care  should  be  taken, 
when  any  of  the  stronger  alkaloids  are  used  in  the  external 
meatus,  to  determine  positively  that  no  perforation  of  the 
membrana  tympani  is  present,  since  when  this  condition  exists 
absorption  may  rapidly  take  place,  either  from  the  mucous 
membrane  of  the  middle  ear  or  by  passage  of  the  drug  into 
the  pharynx  and  subsequently  into  the  stomach — an  event 
which  would  be  followed  by  constitutional  effects.  If  mor- 
phine is  to  be  used,  it  should  be  in  the  form  of  the  alkaloid 
itself  and  not  in  the  form  of  one  of  the  salts,  since  the  simple 
alkaloid  is  mcjre  readily  absorbed  endcrmicallv  than  an\'  of 
its  combinations.  The  cocaine  ear  bath  may  relieve  the  local 
pain  somewhat,  after  the  exfoliation  of  the  superficial  layer 
of  the  epidermis,  and  is  principally  indicated  where  the  sur- 
geon intends  to  incise  the  canal,  in  the  course  of  a  few  hours, 
as  the  slow  absorption  mav  produce  a  certain  amount  of  local 
ana;sthesia. 

While  cocaine  is  of  great  value  as  a  local  anaesthetic,  its 
local  analgesic  action  is  somewhat  limited,  and  for  this  pur- 
pose we  may  more  advantageously  employ  an  alcoholic  solu- 
tion of  menthol,  dilute  carbolic  acid,  creosote,  oil  of  eucalyp- 
tus, thymol,  oil  of  cloves,  or  some  other  aromatic  oil.  Of 
these  remedies,  menthol  is  perhaps  the  most  efficacious  in 
relieving  the  pain,  which  frequently  is  not  confined  to  the 
ear,  but  may  manifest  itself  as  an  intense  neuralgia  of  the 

*  Lehrbuch  der  Ohrenheilkundc,  Vienna,  iSSS,  p.  292. 


TREATMENT— HEAT.  231 

various  branches  of  the  fifth  nerve.  This  use  of  menthol  was 
first  advised  by  Cholewa.* 

In  addition  to  the  relief  of  pain,  its  action  as  a  germi- 
cide makes  it  particularly  valuable,  as  it  affords  a  means  of 
combating  the  local  infective  process  and  of  preventing  the 
formation  of  other  abscesses.  It  is  best  applied  bv  inserting 
into  the  canal  a  long,  narrow  pledget  of  cotton  jircviouslv 
saturated  with  a  ten-  to  twentv-jier-cent  solution  of  the  drug 
in  alb(jlenc  or  olive  oil.  The  relief  obtained  is  often  consid- 
erable. The  only  objection  to  its  use  is  the  fatty  vehicle  with 
which  it  is  incorporated.  As  the  menthol  is  antisej)tic,  this 
is  unimportant,  it  may  be  avoided  by  using  an  alcoholic 
solution  of  menthol  in  tlie  manner  above  described,  or  a  five- 
per-cent  solution  may  be  dropped  into  the  canal  at  intervals, 
if,  for  any  reason,  we  prefer  to  use  carbolic  acid  or  creosote, 
the  preparations  should  not  contain  more  than  ten  percent  of 
the  drug.  Menthol  will  probablv  prove  of  more  value  than 
anv  of  the  other  drugs  mentioned  above. 

When  a  j)atient  is  observed  at  a  stage  tcxj  late  for  us  to 
hope  to  abort  the  attack,  the  local  abstraction  of  blood  and 
the  use  of  cold  applications  arc  worse  than  useless.  The 
application  of  heat,  however,  is  advantageous,  as  it  relieves, 
to  a  very  great  degree,  the  intense  suffering.  Moist  heat, 
however,  is  objectionable.  The  pernicious  [)ractice,  so  com- 
mon, of  applying  a  poultice  to  the  car,  or  (jf  putting  the  heart 
of  a  roast  onion  into  the  canal,  the  outer  lavers  being  applied 
to  the  outside  to  retain  the  heat,  can  not  be  too  strongly  con- 
demned. Such  procedures  favor  the  development  of  suc- 
cessive crops  of  furuncles  bv  causing  a  maceration  of  the 
epidermis  lining  the  canal,  and  aid  subsequent  local  infection. 
While  heat,  theref(jre,  is  one  of  our  most  valuable  agents,  it 
should  be  employed  as  drv  heat.  This  may  be  secured  by 
filling  an  ordinary  flat  bottle  with  hot  water,  wrapping  it  in 
several  layers  of  flannel,  and  resting  the  head  upon  it.  A 
more  elegant  form  of  application  is  the  small  Japanese  pocket 
stove  which  is  sold  in  the  shops,  which  when  once  lighted 
affords  us  a  means  of  applying  dr)'  heat  locally,  the  small  box 
being  wrapped  in  flannel  and  either  secured  to  the  side  of  the 
head  by  means  of  a  few  turns  of  a  bandage — its  light  weight 
rendering  this  practicable — or,  after  being  enveloped  in  sev- 

*  Therap.  Mo.iatshcft,  1889,  No.  6. 


232 


CIRCUMSCRIBED    EXTERNAL   OTITIS. 


eral  layers  of  cloth,  it  may  be  placed  upon  the  pillow  and  the 
patient  ma\-  rest  the  ear  upon  it.  The  common  hot-water 
bag,  found  in  every  household,  can  be  used  in  this  manner, 
but  its  employment  requires  that  the  patient  shall  be  continu- 
ally in  the  recumbent  position,  and  this  is  sometimes  undesir- 
able. In  addition  to  these  measures,  if  we  wish  to  apply  heat 
more  directly  to  the  parts,  I  sometimes  direct  patients  to  cut 
off  the  finger-tips  of  an  old  kid  glove  and  fill  them  with  salt, 
the  open  extremity  being  closed  either  with  a  few  stitches  or 
by  a  few  turns  of  linen  thread.  These  small  salt  bags  may  be 
warmed  upon  a  common  tin  plate  on  a  stove,  or  over  a  gas 
flame  or  oil  lamp,  after  which  they  may  be  inserted  into  the 
meatus.  The  salt  retains  its  heat  for  a  considerable  period, 
especially  if  the  external  parts  are  kept  warm  by  resting  the 
head  upon  a  hot-water  bag  or  similar  device. 

Bearing  in  mind  that  the  process  is  essentially  one  of  local 
infection,  our  efforts  should  be  directed,  not  only  to  the  relief 
of  tiie  local  condition,  but  to  the  prevention  of  the  same  in- 
fective process  at  other  points  in  the  canal.  The  canal  should 
be  thoroughly  cleansed  with  a  warm  antiseptic  solution  by 
means  of  the  syringe,  using  either  carbolic  acid,  in  the  pro- 
portion of  one  to  sixty,  or  the  bichloride  of  mercury  solution, 
about  one  to  eight  thousand.  After  syringing,  which  must 
be  thoroughly  but  gently  done,  the  ear  is  to  be  carefully 
dried  with  small  pledgets  of  cotton  rolled  upon  the  cotton 
holder,  the  manipulation  being  conducted  under  ocular  in- 
spection by  means  of  reflected  light.  The  canal  should  next 
be  filled  with  an  alcoholic  solution  of  boric  acid  of  the 
strength  of  twenty  grains  to  the  ounce.  As  the  sensibility  of 
the  canal  varies  considerably  in  different  subjects,  the  instilla- 
tion of  alcohol  may  cause  pain,  and  it  is  well  to  test  the  sensi- 
tiveness of  the  parts  by  touching  the  walls  of  the  canal  with  a 
pledget  of  cotton  previously  moistened  in  the  solution.  If 
this  causes  pain  the  solution  may  be  diluted  with  water, 
the  quantity  of  water  being  rapidly  diminished  at  each  suc- 
cessive application  as  the  sensitiveness  of  the  parts  becomes 
less.  The  instillation  of  this  alcoholic  solution  should  be  re- 
peated at  least  four  times  during  the  twenty-four  hours,  and 
it  is  often  advantageous  to  repeat  it  still  more  frequently. 
The  syringing  of  the  canal  not  only  removes  any  discharge, 
together  with  exfoliated  epithelial  cells,  but  often  relieves  the 
pain  to  a  very  marked  degree.     Although  frequent  syringing 


TREATMENT— INXISION.  233 

of  the  canal  is  not  advocated  bv  the  majority  of  writers,  it 
has  been  my  custom,  especially  in  dispensary  practice,  to 
direct  the  patient  to  cleanse  the  ear  in  this  manner  several 
times  dailv.  alter  which  the  alcoholic  solution  mav  be  instilled 
in  the  manner  already  described.  If  the  case  is  seen  twice 
daily  by  the  suri^eon  the  patient  need  not  use  the  syringe  at 
home,  but  may  instill  the  boric-acid  solution  without  previous 
cleansing  of  the  canal.  It  is  seldom  necessary  for  the  surereon 
to  see  the  case  as  frequently  as  this,  however,  and  equally 
good  results  are  obtained  if  the  canal  is  syringed  by  the  pa- 
tient twice  or  three  times  dailv,  the  alcoholic  solution  beincr 
used  after  each  irrigation.  The  surgeon  should,  if  j)Ossible, 
see  the  patient  dailv  for  the  first  few  days. 

While  all  of  these  methods  possess  a  certain  amount  of 
value  the  measure  which  stands  pre-eminent  in  the  treatment 
of  this  affection  is  that  of  early  incision.  To  this,  I  think,  we 
should  always  resort  if  our  efforts  to  abort  the  attack  hv  local 
bloodletting  are  not  successful,  or  if  the  patient  is  seen  at  so 
late  a  stage  as  to  ]>reclude  the  possibility  of  it.  It  is  not 
advisable  to  wait  until  the  formation  of  pus  has  taken  ])lace, 
or  even  until  local  tumefaction  is  so  extensive  as  to  be  easily 
recognized  by  ocular  insi)Cction.  The  process  is  most  fre- 
quently tieepiv  situated  at  first,  and  becomes  superficial  only 
a  short  time  bef(jre  spontaneous  ruj)ture  occurs.  Testing  the 
walls  of  the  canal  by  means  of  a  cotton-tipped  f)robe  in  the 
manner  already  described  will  enable  the  surgeon  to  recog- 
nize the  alTected  area  as  certainly  as  if  local  tumefaction  were 
present.  The  point  of  greatest  tenderness  should  be  incised 
deeply  and  freely  with  a  sharp,  short,  strong,  curved  bist(jury, 
the  incision  being  carried  through  the  perichondrium  or  peri- 
osteum, as  the  case  may  be.  It  must  be  of  sutlrtcient  length  to 
relieve  all  tension.  This  procedure  is  excessively  painful — in 
fact,  I  know  of  no  measure  employed  in  surgery  which  causes 
such  exquisite  suffering  as  the  early  incision  of  a  localized  in- 
flammatory area  in  the  canal,  but  the  relief  afTorded  fully  jus- 
tifies the  surgeon  in  inflicting  this  momentary  pain.  'J'he 
beneficial  results  obtained  depend  not  only  upon  the  relief  of 
tension,  but  also  upon  the  very  free  bleeding  which  follows, 
this  latter  result  being  also  beneficial  in  reducing  the  liability 
to  the  development  of  a  similar  condition  in  some  other  part 
of  the  canal.  General  anaesthesia  is  seldom  required,  as  when 
a  properly  formed  instrument  is  used  it  is  only  necessary  to 


234  CIRCUMSCRIBED   EXTERNAL   OTITIS. 

make  the  initial  puncture  under  ocular  inspection,  the  sur- 
geon being  able  to  control  the  extent  and  direction  of  the 
incision  by  his  tactile  sense  quite  as  well  as  bv  the  sense  of 
sight.  The  pain  mav  be  somewhat  lessened  by  the  use  of 
cocaine  ear  baths,  previously  mentioned,  or  by  freezing  the 
part  with  the  chloride-of-methyl  spray.  This  process  is  in 
itself  quite  painful,  and  is  scarcely  of  advantage,  as  the  pain 
is  but  momentary  even  when  no  local  anaesthetic  is  used. 

After  the  focus  of  intlammation  has  been  incised  the 
rules  already  given  concerning  cleansing  of  the  parts  should 
be  carried  out,  with  the  exception  that  any  alcoholic  solution 
applied  to  the  canal  must  be  considerably  reduced  in  strength, 
as  otherwise  severe  pain  would  be  produced  by  its  instilla- 
tion. The  cleansing  may  be  effected  cither  by  the  ordinary 
ear  syringe  (Fig.  82),  the  small  soft-rubber-ball  svringe,  or,  if 
considerable  pain  persists,  a  continuous  irrigation  of  the  canal 

mav  be  employed.  This 
mav  be  carried  out  by 
using  the  ordinary  foim- 
tain  syringe.  A  warm 
antiscj)tic  solution,  cither 
of  bichloride  of  mercurv.  one  to  eight  thousand,  or  of  boric 
acid,  in  the  proportion  of  twenty  grains  to  the  ounce,  may  be 
allowed  to  flow  over  the  parts  continuously  for  a  period  of 
ten  to  twenty  minutes.  If  this  is  done  immediately  after  inci- 
sion, the  attendant  pain  quickly  disappears,  ^vhile  the  warmth 
of  the  application  favors  free  ha?morrhage  from  the  wound. 
This  local  depletion  both  relieves  the  pain  and  renders  the 
reparative  process  more  rapid.  After  free  incision  the  relief 
is  usually  immediate,  and  in  the  course  of  twenty-four  hours 
the  parts  assume  more  nearly  their  normal  contour.  The 
discharge,  however,  continues  for  a  few  days,  during  which 
time  the  infection  of  adjacent  areas  is  very  liable  to  take  place 
unless  attention  is  paid  to  the  systematic  cleansing  of  the 
parts,  as  above  advised.  Ordinarily  the  abscess  cavity  be- 
comes completely  obliterated  and  the  canal  wall  resumes  a 
perfectly  smooth  and  normal  outline  ;  exceptionally,  where 
the  process  has  been  very  deep  seated  and  a  considerable  area 
has  been  involved,  exuberant  granulations  spring  up  about 
the  margins  of  the  opening.  If  very  large,  these  may  be  re- 
moved by  means  of  the  cold  snare  or  sharp  curette.  Usually, 
however,  they  are  so  small  as  to  require  siiuple  cauterization 


Fig.  82. — Hard-rubber  ear  syringe. 


TREATMENT— INTERNAL   MEDICATION. 


235 


bv  a  chemical  ai^cnt.  \Vc  may  employ  for  this  purpose  cither 
chromic  acid  or  nitrate  of  silver,  the  former  to  be  applied  in 
substance,  a  minute  bit  of  the  acid  beini^  fused  upon  the  tip 
of  a  metal  probe  and  applied  lig^htly  to  the  efflorescent  tissue, 
after  this  has  been  previously  dried  bv  a  pleds^^ct  of  cotton  ; 
anv  excess  of  acid  must  be  immediately  wijied  awav  bv  means 
of  a  cotton-tipjK'd  probe,  as  otherwise  the  ai^ent  quicklv 
spreads  over  tiie  walls  of  the  canal,  and  severe  diffuse  inllam- 
mation  mav  result.  The  nitrate  of  silver  may  be  used  in  the 
same  manner,  or  mav  be  applied  as  an  aqueous  solution  of 
from  two  hundred  and  forty  to  four  hundred  and  eight v 
grains  to  the  ounce.  I  |)refer  the  chromic  acid,  as  in  mv 
hands,  at  least,  it  has  never  caused  any  reaction,  while  oc- 
casionallv  the  silver  preparations  excite  a  severe  secondary 
inflammation  of  the  walls  of  the  canal.  If  the  destructive 
process  has  invt)lved  not  only  the  integument,  but  also  the 
underlving  cartilaginous  or  bony  structures,  rather  extensive 
necrosis  mav  take  j)lace,  retarding  the  healing  process  to  a 
marked  degree.  In  such  an  event  it  is  well  thoroughly  to 
curette  the  cavitv.  removing  all  diseased  tissue  by  means  of 
the  sharp  sj)oon,  alter  which  rapid  healing  ensues. 

In  addition  to  the  local  measures  here  advocated,  the  con- 
dition of  the  general  health  should  alwavs  be  borne  in  miiitl 
as  furnishing  a  prominent  predisposing  cause  of  local  disease. 
Especial  attention  should  be  jiaid  to  the  gastro-intestinal  canal ; 
constipation,  if  present,  should  be  relieved,  or  disorders  of  the 
digestion  corrected  bv  the  administration  of  alkalies  or  acids, 
as  seem  indicated.  One  of  the  most  common  causes  under- 
lying this  afTection  is  simple  anaemia.  This  is  best  combated 
bv  the  use  of  some  of  the  ferruginous  pi-ei)arations.  Prob- 
ably no  specific  exists  upon  which  we  can  depend  to  {pro- 
duce anv  marked  elTect  upon  the  prt)gress  of  the  local  in- 
flammation. Sulphide  of  calcium,  so  much  used  in  general 
furunculosis,  has  been  frequently  advocated,  and  for  a  con- 
siderable period  I  administered  it  regularly  in  every  case,  but 
was  unable  to  perceive  anv  beneficial  results  from  its  action. 
If  its  use  seems  indicated  in  any  instance,  it  is  best  given  in 
the  form  of  a  pill  containing  one  sixth  of  a  grain  of  the  drug. 
One  pill  is  to  be  taken  every  hour  for  six  doses,  after  which 
the  interval  mav  be  reduced  to  every  two  hours.  After  this 
medication  has  been  continued  for  twenty-four  or  thirt3^-six 
hours  the  doses  may  be  repeated  less  frequently,  say  at  inter- 


236  CIRCUMSCRIBED   EXTERNAL   OTITIS. 

vals  of  every  four  or  six  hours.  It  will  generally  be  found, 
however,  to  exert  very  little  action  upon  the  disease.  The 
internal  administration  of  drugs  intended  to  relieve  the  in- 
tense suffering  of  the  patient  is  alwavs  advisable  in  the  very 
early  stages.  There  can  be  no  question  that  the  relief  of  pain 
for  a  period  of  six  or  eight  hours,  when  the  process  is  in  its 
incipiencv,  does  exert  a  certain  permanent  beneficial  action, 
the  tendency  being  to  increase  the  resisting  power  of  the  pa- 
tient. By  relieving  the  pain  or  rendering  it  more  bearable, 
our  efforts  toward  aborting  the  attack  will  be  more  successful. 
It  is  to  be  borne  in  mind  also  that  the  pain  will  continue  for 
only  a  comparatively  short  period  of  time  ;  hence,  the  admin- 
istration of  opiates  is  not  open  to  the  objection  that  the  pa- 
tient is  liable  to  acquire  the  opium  habit.  In  the  later  stages 
of  the  affection  analgesics  are  contraindicatcd,  as  they  may 
mask  mastoid  involvement. 

Chronic  Circumscribed  External  Otitis. 

But  few  words  need  be  said  in  consideration  of  a  circum- 
scribed local  inflammation  of  long  duration.  It  is  usually 
svmptomatic  of  some  affection  of  the  deeper-seated  struc- 
tures, either  cartilaginous  or  bony.  In  the  former  instance 
it  results  from  a  very  severe  form  of  the  disease  just  described, 
while  in  the  latter  case  it  is  usuallv  indicative  of  some  patho- 
logical process  within  the  mastoid  cells,  and  is  situated  in  the 
bony  canal.  The  condition  which  clinically  may  be  considered 
as  belonging  to  this  group,  although  from  a  pathological 
point  of  view  it  should  be  placed  elsewhere,  is  that  met  with 
when  suppuration  takes  place  in  the  sebaceous  cyst  located 
in  the  meatus.  These  neoplasms  usuallv  occur  on  the  an- 
terior or  inferi(jr  walls  01  the  canal,  near  the  orifice,  and  either 
discharge  spontaneously,  or,  if  their  contents  have  been  evacu- 
ated by  surgical  means',  persist  for  a  K)ng  period,  the  lining 
membrane  being  of  such  a  nature  that  adhesive  inflammation 
with  resultant  obliteration  of  the  sac  is  impossible.  The 
cavity  refills  slowly  after  each  evacuation  of  its  contents,  and 
the  symptoms  of  obstruction  of  the  meatus  due  to  the  pres- 
ence of  the  tumor,  together  with  intermittent  discharge  at 
somewhat  irregular  intervals,  are  repeated  for  an  indefinite 
period,  I'nder  these  circumstances  simple  incision  does  no 
good,  and  will  afford  but  temporary  relief.  The  lining  mem- 
brane of  the  sac  must  cither  be  dissected  out  entire,  or,  if  this 


CHRONIC   CIRCUMSCRIBED   EXTERNAL   OTITIS.         237 

is  impossible  on  account  of  the  location  of  the  tumor,  it  must 
be  completely  destroyed  by  the  curette,  after  which  recovery 
is  pronijjt. 

We  shall  consider  circumscribed  inflammation  of  the  bony 
meatus  dependent  upon  mastoid  inflammation  in  the  section 
devoted  to  mastoid  disease. 


CHAPTER   XII. 


DIFFUSE   EXTERNAL   OTITIS. 


This  afTcctic^n  may  occur  in  either  acute  or  chronic  form, 
and,  as  its  name  imj)lies,  constitutes  an  inflammation  of  the  ex- 
ternal auditory  meatus,  in  which  the  local  condition,  instead  of 
beini^  confined  to  a  small  area,  involves  cither  the  entire  canal 
or  a  very  large  portion  of  it,  the  line  of  demarcation  between 
the  normal  and  affected  areas  not  being  clearly  marked,  but 
mergincr  orraduallv  into  each  other.  Since  the  acute  form  of 
the  disease  is  frequently  dependent  for  its  cause  upon  a  pre- 
viously existing  chronic  inflammatory  process,  we  will  con- 
sider, first,  the  chronic,  and  afterward  the  acute  affection. 

Chronic  Diffuse  External  Otitis. 

This  general  term  applies  to  the  superficial  extent  of  the 
lesion  rather  than  to  its  severity,  and  comprises  every  degree 
of  chronic  inflamniatory  condition  of  a  diffuse  character,  from 
those  cases  in  which  only  the  superficial  layer  of  the  epider- 
mis is  involved  to  instances  where  not  only  the  cutaneous 
lining  is  affected  through  its  entire  depth,  but  the  cartilagi- 
nous and  bony  framework  as  well. 

iEtiology. — This  disease  is  less  dependent  upon  constitu- 
tional conditions  than  is  the  circumscribed  form  of  inflam- 
mation. Traumatism  plays  a  very  prominent  part  in  its  prd? 
duction.  The  impression  so  common  among  many  that  the 
external  auditory  meatus  must  be  subjected  to  thorough 
cleansing  by  means  of  the  corner  of  the  towel  wound  up  so 
as  to  permit  its  entrance  into  the  lumen  of  the  canal,  or  by  the 
introduction  of  various  ear  sponges,  ear  spoons,  etc.,  furnishes 
one  of  the  most  fruitful  sources  of  mild  but  persistent  inflam- 
matory conditions  of  diffuse  character.  Wounds  of  the  canal 
walls,  either  inflicted  by  mechanical  violence  or  resulting  from 
the  bites  of  insects  which  find  their  way  into  the  meatus,  are 
also  among  the  most  frequent  causes  of  the  disease.     The  ap- 

(238) 


ETIOLOGY— PATHOLOGY. 


239 


plication  of  oleaginous  substances  to  the  walls  of  the  canal, 
for  the  relief  of  pain  in  the  ear,  or  sometimes  for  toothache, 
is  practiced  not  uncommonly  among  the  laitv,  and  furnishes  a 
source  of  irritation  to  the  lining  of  the  canal.  Foreign  bodies, 
introduced  bv  mistake  or  design,  bv  their  presence  aUnie  fre- 
quently cause  a  condition  of  diffuse  iiitlamniation.  The  most 
common  cause  of  the  condition  is  some  affection  of  the  mid- 
dle ear  attended  by  a  purulent  discharge.  When  the  walls  of 
the  canal  are  continually  bathed  with  such  a  secretion,  thev 
socjn  lose  the  superficial  layer  of  ejiithelium  tiirough  the  com- 
bined action  of  warmth  and  moisture.  Thus  a  tlenuded  sur- 
face is  left,  through  which  infection  may  take  place.  This  is 
more  commonly  met  with  among  that  class  of  indiyiduals  who 
pay  little  attention  to  habits  of  cleanliness,  and  hence  make  no 
effort  t(j  keep  the  passage  free  from  secretion  by  frequent  irri- 
gation. Among  the  more  uncommon  causes  is  the  develop- 
ment of  vegetable  parasites  within  the  canal.  These  minute 
organisms  attach  themselves  firmly  to  the  walls  of  the  mea- 
tus, and  grow  for  an  indefinite  period.  As  their  growth  con- 
tinues they  become  firmly  imbedded  in  the  deeper  layers  of 
the  integument,  and  their  removal  results  in  the  loss  of  the  su- 
perficial epithelium  antl  an  exposure  of  the  underlying  cells. 
It  is  probable  that  the  condition  never  engrafts  itself  upon  a 
perfectly  healthy  integument — that  is.  one  in  which  the  horny 
layer  of  the  skin  is  unbroken  throughout  the  entire  extent 
of  the  canal.  If.  however,  the  integument  at  any  jtlace  is 
abraded,  the  moist  surface  forms  an  excellent  soil  lor  the  de- 
velopment of  a  parasite.  Having  once  taken  root,  the  fungus 
may  increase  indefinitely  bv  subsequent  growth.  The  con- 
tinued presence  of  fungi  produces  an  effect  similar  to  that  of 
a  foreign  body — that  is.  it  causes  an  inflammation  of  the  lining 
of  the  canal. 

Constitutional  causes,  we  have  said,  are  not  important  fac- 
tors in  the  production  of  this  disease ;  we  make  one  excep- 
tion, however,  in  the  case  of  eczema  of  the  canal,  which,  like 
eczema  in  other  parts  of  the  body,  is  an  evidence  of  some  dia- 
thetic condition. 

Fathology.  —  An  affection  dependent  upon  such  a  variety 
of  causes  must  necessarily  present  physical  characteristics 
differing  greatly.  Under  the  milder  types  we  would  include 
those  cases  of  augmented  glandular  activity  resulting  in  an 
increase  in  amount  of  the  secretion  from  the  sebaceous  follicles 


240 


DIFFUSE    EXTERNAL   OTITIS. 


with  which  the  skin  is  supplied.  When  the  inflammation  in- 
volves the  inter-glandular  tissue,  as  in  eczema  of  the  canal, 
there  is  a  certain  amount  of  infiltration  of  the  deeper  layers  of 
the  cutis,  causing-  the  superficial  epithelium  to  be  cast  off  more 
rapidly  than  under  normal  conditions.  According  to  the  de- 
gree of  the  infiltration  of  the  integument,  a  greater  or  less 
amount  of  serum  exudes,  which,  washing  away  the  desqua- 
mated cells  when  the  transudation  is  profuse,  leaves  a  red, 
smooth,  glistening  surface;  or  when  less  fluid  is  poured  out  it 
dries  upon  the  walls  of  the  meatus,  forming  with  the  desqua- 
mated epithelial  cells  yellowish  crusts,  which  adhere  to  the 
canal  walls  and  partially  or  completely  occlude  the  passage. 
If  the  process  is  allowed  to  progress,  actual  hypertrophic 
changes  take  place  in  the  basement  membrane  and  the  meatus 
is  gradually  converted  into  a  tube  of  very  small  calibre,  the 
opposing  walls  lying  nearly  in  contact.  An  inflammation  of 
the  external  canal  occurring  in  the  bony  portion,  where  the 
cutaneous  lining  is  verv  thin,  and  where  it  constitutes  the  peri- 
osteum, mav  extend  to  the  osseous  tissues  and  produce  the 
symptoms  which  characterize  an  inflammation  of  the  mastoid 
process,  or,  where  the  Rivinian  segment  is  imperfectly  closed, 
it  may  pass  bv  continuity  of  structure  into  the  tympanum  and 
excite  an  inflammation  within  this  cavity. 

When  the  inflammation  of  the  canal  is  due  to  the  presence 
of  a  foreign  bodv,  or  follows  a  wound  of  the  canal,  a  circum- 
scribed acute  inflammation,  or  the  development  within  the 
meatus  of  a  vegetable  parasite,  the  changes  which  take  place 
vary  in  intensity,  but  are  of  the  same  character  as  those  above 
described.  The  superficial  epithelium  is  thrown  off  rapidlv, 
the  deeper  lavers  of  the  cutis  are  infiltrated  with  round  cells 
and  become  thickened,  and  tissue  hypertrophy  finally  results. 
In  the  more  severe  cases  tissue  necrosis  may  take  place  or  by 
extension  the  underlying  bone  mav  become  involved. 

In  some  cases  we  find  the  activity  of  the  inflammatory 
process  directed  especially  toward  a  rapid  proliferation  of  the 
superficial  epithelial  laver  of  the  integument.  The  flat  pave- 
ment cells  are  thrown  off  rapidly,  and,  aggregating  in  the  mea- 
tus, form  a  compact  mass,  which  completely  fills  the  deeper 
portion  of  the  canal.  From  the  increase  in  the  blood  supply 
incident  upon  inflammation  a  small  amount  of  serum  is  tran- 
suded ;  the  fluid  moistens  the  compact  epithelial  mass  and 
causes  it  to  increase  in  voknuc.      lu  this  way  great  pressure 


PATHOLOGY 


241 


is  exerted  upon  the  surroundino^  bony  walls,  which  may  be 
absorbed  or  become  necrotic,  or  the  pressure  may  be  so  grad- 
ual as  to  interfere  but  little  with  the  nutrition  of  the  parts, 
and  result  in  a  dilatation  of  the  deeper  portion  of  the  meatus 
by  crowding  backward  that  part  of  the  wall  which  separates 
the  canal  from  the  mastoid  cells,  so  as  to  obliterate  the  pneu- 
matic spaces  of  this  portion  of  the  temporal  bone. 

In  the  above  consideration  we  have  followed  the  extension 
of  the  process  from  the  canal  inward  toward  the  deeper  por- 
tions of  the  conducting  channel.  But  a  dilTuse  external  otitis 
may  be  of  a  consecutive  nature:  that  is,  the  deeper  parts  may 
be  involved  first,  and  by  extension  produce  an  inflammation 
of  the  walls  of  the  meatus.  This  is  particularly  true  where 
the  deep  osseous  canal  is  the  site  affected.  The  upper  and  pos- 
terior portions  of  the  canal  at  this  point  form  the  inferior  or 
anterior  walls  of  the  mastoid  process;  hence,  an  inflammation 
involving  the  mastoid  antrum  and  the  smaller  pneumatic 
spaces  frecjucntlv  produces  an  inllammation  of  the  canal  in 
this  region  ditfuse  in  character,  the  jtroccss  bfing  as  much  a 
mastoid  jjcriostitis  as  it  the  outer  wall  of  the  mastoid.  Iving 
immediately  behind  the  ear, 
were  the  j)art  affected. 

While  it  lies  beyond  the 
province  of  this  work  to  give 
any  detailed  account  of  the 
niicroscf)pic  apj)earances  of 
the  various  forms  of  vejreta- 
ble  parasites  found  in  the 
meatus,  certain  characteris- 
tics which  are  common  to 
all  of  these  should  be  under- 
stood, in  order  that  a  diag- 
nosis may  be  made  between 
the  purely  epithelial  or  des- 
quamative type  of  inflamma- 
tion and  ihat  form  dependent 
upon  the  [)resencc  of  fungi. 
These  fungi  present  under 
the  microscope  long  fibres  or  hyphas  of  a  double  contour, 
either  completely  transparent  or  slightly  granular.  These 
fibres  divide  into  branches  dichotomously  (Fig.  S3),  which 
terminate  in  a  globular  head  or  fruit-sac  (sporangium)  (Fig.  84) 
17 


Fig.  83. — I  >cvelopment  of  a  fungus.    G,  G, 
.Sporangia  ;  //,  Hyphae.     ((jruber.) 


242 


DIFFUSE   EXTERNAL   OTITIS. 


filled  with  minute  spherical  spores.  Examination  of  the  fruit- 
sac  at  a  certain  stage  of  development  will  show  thin  filaments 
radiating  from  a  central  stalk  toward  the  periphery  through 
the   mass  of   minute   spores.     These  fresh  filaments  in   turn 


Fig.  84. — Microscopical  characteristics  of  otomycosis. 
6",  G,  Sporangia  ;  //,  Hyph«.     (Gruber.) 

develop  sporangia,  and  the  process  repeats  itself  indefinitely. 
The  recognition,  then,  of  the  mycelial  filaments  or  of  the 
fruit-heads  containing  the  spores  establishes  the  diagnosis  of 
parasitic  inflammation. 

Symptomatology. — The  svmptoms  differ  in  severity  in  ac- 
cordance with  tiic  degree  of  intensity  of  the  local  process.  In 
mild  cases  a  sense  of  constant  irritation  or  itching  in  the  canal 
is  the  most  prominent  symptom,  the  patient  continuallv  at- 
tempting to  relieve  this  by  the  insertion  of  the  tip  of  the  little 
finger  as  far  into  the  meatus  as  possible  ;  this,  naturally,  only 
tends  to  aggravate  the  condition  it  is  intended  to  relieve. 
When,  either  from  increased  glandular  activity,  as  in  sebor- 
rhoea,  or  from  actual  inflammation,  as  in  eczema  or  otomvcosis, 
the  canal  becomes  to  an  extent  occluded,  either  bv  the  scale- 
like sebaceous  crusts,  or  by  aggregations  of  epithelium  re- 
sulting from  eczema,  or  bv  masses  of  vegetable  fungi,  certain 
symptoms  dependent  upon  this  occlusion  manifest  themselves. 
These  mav  consist  in  an  iiupairment  of  the  hearing,  varying 
in  degree  according  to  the  extent  of  (obstruction,  or  there  may 
be  tinnitus  caused  by  the  congestion  which  the  presence  of  the 


SVM  PTOM  ATOLOGY. 


243 


foreign  substance  induces,  or  certain  reflex  symptoms  may 
manilest  themselves,  such  as  severe  pain  spreading  over  the 
distribution  of  the  fifth  nerve,  headache,  either  general  or 
local,  and,  rarely,  disturbances  of  a  graver  nature,  dispropor- 
tionate in  severity  to  the  local  condition.  Thus,  instances  of 
epileptiform  attacks  have  been  traced  to  inflammatory  condi- 
tions within  the  canal,  while  svmptoms  referable  to  the  oppo- 
site ear  may  also  be  produced  by  a  chronic  inflammation  of 
the  external  auditory  meatus  of  one  side.  A  symptom  fre- 
quently  complained  of  is  that  of  autophonv.  the  patient's  own 
voice  seeming  to  come  from  the  affected  side.  This  occurs 
only  when  the  lumen  of  the  canal  is  considerably  narrowed. 

Cough  is  a  not  infrequent  symptom  of  the  affection,  and 
may,  in  fact,  be  the  fust  to  attract  the  attention  of  the  patient 
and  cause  him  to  seek  advice.  In  all  cases  of  cough,  even  al- 
though apparently  exjilainable  upon  other  causes,  it  is  always 
well  to  examine  the  exteiiial  auditory  meatus,  as  an  accumu- 
lation (jf  any  foreign  material,  resulting  cither  from  desquama- 
tion of  the  ejjithelial  lining  of  the  canal  or  from  the  aggrega- 
tion of  a  mass  of  aspergillus,  may  cause  a  reflex  cough.  As 
the  affection  increases  in  severity  a  discharge  may  make  its 
a[)pearance  at  the  orifice  of  the  meatus.  This  discharge  is 
ordinarily  scanty,  and,  in  fact,  may  be  so  small  in  amount  as  to 
appear  in  the  form  of  crusts  about  the  margin  of  the  meatus, 
the  fluid  elements  having  been  cvaj>orated.  When  more  pro- 
fuse the  discharge  is  watery  in  character,  but  is  never  large 
in  amount.  In  the  milder  cases,  due  to  an  inflammation  of  the 
glandular  structures  alone,  the  discharge  aj)i)ears  in  the  form 
of  minute  scales,  which  are  oily  to  the  touch,  on  account  of  the 
fatty  matters  which  they  contain.  Occasionally,  in  cases  of 
very  long  duration,  the  inflammation,  instead  of  producing  a 
fluid  discharge,  causes  a  j)r()liferati()n  of  the  epithelial  lining 
of  the  meatus.  The  superficial  ej»ithelial  cells  are  rapidly  cast 
off,  and,  aggregating  intt)  masses,  remain  in  the  canal  for  a  long 
period.  These  masses  of  desquamated  epithelium  absorb  the 
watery  secretion  which  the  thickened  cutaneous  lining  of  the 
canal  exudes,  and  as  the  process  continues  increase  steadily  in 
size.  From  the  fact  of  their  slow  increase  in  volume  these 
epithelial  plugs  exert  a  great  amount  of  pressure  upon  the 
walls  of  the  canal,  leading,  in  some  cases,  to  a  dilatation  of  the 
bony  canal,  either  by  causing  an  absorption  of  the  osseous  tis- 
sue or  by  crowding  the  thin  bony  wall  upward  and  outward 


244 


DIFFUSE    EXTERNAL   OTITIS. 


toward  the  mastoid  cells,  which  become  correspondingly  di- 
minished in  size.  At  the  same  time  the  osseous  tissue  under- 
goes certain  structural  changes  as  the  result  of  this  mechanical 
irritation,  so  that,  instead  of  presenting  the  ordinary  cancellous 
appearance,  it  becomes  converted  into  a  hard,  ivorv-like  sub- 
stance of  uniform  density.  This  change  may  extend  through- 
out the  entire  mastoid,  all  the  airspaces  being  obliterated  with 
the  exception  of  the  antrum,  or,  if  the  pressure  is  still  greater, 
the  bony  walls  of  the  canal  may  be  absorbed  entirely,  and  the 
upper  part  of  the  tympanic  cavity  and  the  mastoid  cells  may 
thus  be  continuous  with  the  external  auditory  meatus. 

Glandular  enlargement  is  not  uncommon  as  the  result  of 
chronic  inflammation  oi  the  external  meatus,  and  when  the 
glands  just  below  the  lobule  are  effected  a  mistake  in  diagno- 
sis is  possible,  the  case  i)rcsenting  manv  of  the  characteristics 
of  a  perforation  through  the  tip  of  the  mastoid  process. 

We  have  spoken  of  dilatation  of  the  bonv  canal  as  the  re- 
sult of  a  desquamative  inllammation  with  the  consequent  ab- 
sorption or  displacement  of  the  bonv  walls.  The  ojipositc 
effect  mav  be  produced,  however,  if,  instead  of  causing  a  des- 
quamation of  the  supcrhcial  epithelium,  the  deeper  lavers  of 
the  integument  are  the  seat  of  inllammation;  in  these  cases 
the  lumen  ot  the  canal  iiiav  l)cct)ine  verv  narrow — in  fact,  it 
mav  be  so  diminished  in  si/e  as  to  admit  onlv  the  smallest 
probe.  This  diminution  in  calibre  is  due  to  an  actual  hvper- 
trophic  osteitis  rather  than  to  any  thickening  in  the  soft  parts. 
This  change  frequentlv  takes  place  in  the  cases  of  diffuse  ex- 
ternal otitis  which  accompany  a  chronic  suppurative  process 
within  the  middle  ear.  Instead  of  narrowing  the  calibre  of 
the  canal  uniformlv,  certain  limited  areas  within  the  canal 
may  be  affected,  producing  what  is  known  as  an  exostosis  or 
a  circumscribed  bony  growth,  which  projects  to  a  greater 
or  less  extent  into  the  passage.  These  growths  are  most  fre- 
quently situated  near  the  drum  membrane,  and,  according  to 
their  size",  interfere  with  the  function  of  audition. 

Diagnosis. — The  diagnosis  of  chronic  diffuse  external  otitis 
will  be  determined  both  by  external  manijuilation  and  by  ex- 
amination by  means  of  the  speculum.  \Vc  have  to  distinguish 
by  palpation  between  an  affection  contmed  to -the  canal  and 
one  involving  the  mastoitl  {)rocess,  as  the  superior  and  a  por- 
tion of  the  posterior  walls  of  the  meatus  form  the  anterior  and 
inferior  wall  of  the  mastoid  pr(,)cess.     It  would  seem  that  this 


DIAGNOSIS. 


^45 


fliffcrentiation  is  rather  supcrlluous.  but  the  author  intends 
here  to  separate  those  cases  in  which  the  affection  of  the  canal 
is  the  prominent  feature,  tlic  mastoid  bein<^  involved  to  so 
slio^ht  an  extent  as  to  trjve  rise  to  no  svmptoms  and  to  require 
the  emj)lovment  of  no  sjiccial  measures,  from  those  cases  in 
which  tlie  affection  of  the  canal  is  merelv  s\riij)tomatic  of  a 
deep-seated  inflammation  within  the  mastoid,  in  which  treat- 
ment must  be  directed  to  the  mastoiil  inllatumation  as  the  pri- 
mary disease.  When  the  affection  is  conlmed  to  the  canal, 
pressure  behind  the  ear,  directed  backwartl  and  inward,  will 
fail  to  elicit  tenderness  ;  if  the  pressure  is  exerted  in  such  a 
way  as  to  move  the  tibro-cartila<xinous  meatus,  verv  marked 
tenderness  will  be  elicited.  In  the  same  wav  pressure  from 
below,  above,  or  in  front  of  the'  canal  will  cause  more  i)ain 
than  if  made  directlv  over  the  mastoid  process.  The  ajipear- 
ance  presented  upon  inspection  bv  reflected  li^j^ht  will  varv 
accordiuL!^  to  the  cause  and  character  of  the  affection,  as  well 
as  with  its  intensitv.  In  the  milder  cases,  under  which  we  in- 
clude seborrluLM.  eczema,  and  a  chronic  otitis  externa  diffusa 
caused  bv  an  aspergillus,  inspection  will  slmw  tiiat  the  walls 
of  the  canal  are  covered  either  jiartiallv  or  com|»lelelv  with 
some  loreiu^n  substance.  In  seborrluea  this  will  be  conlmed 
alnntst  entirelv  to  the  cartilaginous  meatus,  and  the  deposit 
will  apj)ear  to  be  made  up  of  small,  thin,  vtllowish  crusts 
which  are  easilv  detached  and  upon  compression  between 
the  tinsfer  and  thumb  have  an  oily  feel.  The  surface  from 
which  these  small  scales  are  detached  is  somew  hat  reddened, 
but  not  moist.  In  eczema  the  crusts  are  larger,  adhere  more 
closelv  to  the  walls  of  the  meatus,  and  are  evidently  made  up 
of  desquamated  cells  which  have  been  moistened  with  serum 
and  have  become  ajjfjlutinated  into  a  mass.  This  collection 
of  cast-off  cells  has  subsequently  dried  into  thick,  irregular, 
vellowish-brown  crusts.  Here  the  affection  extends  from  just 
within  the  orihce  of  the  meatus  to  the  drum  membrane  itself; 
the  crusts  are  detached  with  some  difficult v,  their  former  lo- 
cation {)resentinsf  as  a  red,  moist  area,  which,  upon  beings  dried 
with  a  cotton  pled<^et,  quicklv  becomes  coated  with  a  thin 
serous  transudate.  Inspection  and  tactile  manipulation  by 
means  of  the  probe  demonstrate  an  evident  thickening-  of  the 
deej)er  layers  of  the  cutis  of  the  canal. 

In  the  milder  forms  of  aspcrgillus  the  canal  walls  are  cov- 
ered, sometimes  throujrhout  their  entire  extent,  at  other  times 


246 


DIFFUSE   EXTERNAL   OTITIS. 


only  here  and  there,  by  a  whitish  or  vellowish-white  deposit, 
which  seems  to  be  closely  adherent  to  the  underlying  struc- 
tures (Fig.  85).  The  entire  lumen  of  the  canal  may  appear 
somewhat  narrow.  Upon  using  the  cotton  holder  to  wipe 
out  the  meatus,  in  order  that  inspection  may  be  more  exact, 
the  parts  may  be  found  to  be  moist,  the  instrument  remoying 
from  the  walls  of  the  canal,  in  addition  to  the  moisture  which 
it  has  absorbed,  thin,  moist  flakes  or  scales,  usually  of  a  whit- 
ish color,  the  surface  from 
which  they  were  removed 
appearing  denuded.  Upon 
attempting  thoroughly  to 
clear  the  canal  it  will  often 
be  found  possible  to  de- 
tach relatiyely  large  thin 
sheets  of  this  deposit,  of  a 
white  or  a  dirty  yellowish- 
brown  color,  haying  the 
consistency  of  moistened 
paper.  In  this  way  a  com- 
plete cast  of  the  canal  from 
Fig.  85.— Otomycosis.  The  canal  is  lined  fKp  verv  orifire  of  the  men 
with  a  thin  deposit  which  covers  the    '■''^  ^^^}  orince  oi   inc  mea- 

walis  and  the  surface  of  the  niembraiia     tUS  may  bc  obtained.      If  the 
tympani.     The    punctate    areas   on   the         _  '     ,  ^     ♦  i 

membrana  are  caused  by  the  increased     1"'(>CCSS     nas    Spread     tO    the 

growth  of  the  fungus  in  these  situations,    (imin    membrane    the    cast 

(Natural  sue.)  . 

Will  lorm  a  bnnd  sac,  the 
closed  extremity  bearing  the  imprint  of  the  various  landmarks 
of  the  membrana  tympani.  This  deposit  is  due  to  the  growth 
of  low  vegetable  organisms  upon  the  walls  of  the  meatus.  The 
special  species  of  plant  life  can  only  be  determined  by  micro- 
scopic investigation  ;  the  varieties  met  with  are  extremely 
numerous,  but  as  the  treatment  of  the  different  forms  does 
not  vary  essentially  it  is  unimportant  to  discuss  the  condititMi 
at  length  in  a  treatise  devoted  particularly  to  clinical  otology. 
Certain  macroscopic  features,  however,  enable  us  to  make  a 
reasonably  accurate  diagnosis  as  to  the  particular  variety  of 
plant  present  in  a  given  case.  A  white  deposit  usually  con- 
sists of  the  aspergillus  glaucus.  Another  variety  is  the  asper- 
gillus  flavus,  the  microscopic  features  of  which  are  shown  in 
Fig.  86,  while  more  rarely  we  find  the  walls  of  the  canal  and 
the  surfaces  of  the  membrane  covered  with  irregular  black 
spots,  a  little  smaller  than  the  head  of  a  pin,  which  are  the 


DIAGNOSIS. 


247 


^ 


^ 


f" 


sporangia  of  the  aspergillus  niger.  The  growth  of  this  latter 
is  seldom  as  extensive  as  that  of  the  other  two  varieties.  A 
microscopic  examination  alone  will  enable  us  to  distinguish 
with  certainty  between  otomycosis  and  the  milder  forms  of 
des(iuamaiive  inflammation  involving  the  canal.  The  greater 
C(^nsistency  of  the  epithelial  plug  and  the  imbricated  arrange- 
ment of  the  scales  usually  give  the  observer  a  hint  as  to  the 
nature  of  the  condition  present.  It  is  probable  that  in  no 
case  do  these  U)w  forms  ot 
vegetable  lite  take  root  upon  a 
perfectlv  health v  cutaneous  sur- 
face ;  it  is  necessary  that  the 
epithelium  should  be  wanting 
over  a  small  area  at  least,  in 
order  that  the  plant  may  de- 
velop. Hence  it  is,  that  para- 
sitic inflammation  of  the  mea- 
tus is  usuallv  coexistent  with 
some  condition  of  the  external 
canal  or  lA  the  middle  car  char- 
acterized bv  the  presence  of 
moisture.  The  cj)ithclium  of 
the  canal  is  thus  softened  and 
thrown  off.  leaving  a  surface 
which  forms  an  excellent  site 
for  the  dc\(.lo|>ment  of  a  low  form  of  plant  life,  the  growth 
being  stimulated  at  the  same  time  bv  the  presence  of  moistuie. 
The  mere  j)resence  of  aspergillus  spores  in  anv  aggregation 
of  foreign  matter  which  mav  be  removed  from  the  meatus  does 
not  warrant  a  diagnosis  of  parasitic  inflammation  of  the  canal, 
since  it  is  usual  to  hnd  them  in  ceruminous  masses,  or  upon 
anv  foreign  bodv  which  has  remained  in  the  canal  tor  a  con- 
siderable length  of  time.  It  is  onlv  when  they  constitute  the 
bulk  of  the  mass  that  this  constitutes  a  lesion  proper. 

The  diagnosis  of  the  desquamative  form  of  inflammation 
will  be  based  uj)on  the  presence  in  the  deep  meatus,  of  a  com- 
pact mass,  whitish  in  color,  which,  although  easily  penetrated 
bv  the  probe  or  curette,  is  removed  with  considerable  diffi- 
culty. The  walls  of  the  canal  are  ordinarily  moist  and  pre- 
sent a  sodden  appearance,  the  superficial  epithelium  being 
easily  wiped  off  bv  means  of  the  cotton  pledget,  which,  upon 
investigation,  is  found  to  be  covered  with  thin  white  flakes  of 


Fig. 


6",  Sporangium  ;  //,  llypha.    ((jiul)cr.) 


248  DIFFUSE    EXTERNAL    OTITIS. 

irregular  size  and  shape.  If  the  probe  is  immersed  in  water 
these  are  seen  to  spread  out  and  float  upon  the  surface,  but 
are  not  dissolved  by  the  fluid  ;  they  are  really  the  epidermal 
cells  lining  the  canal,  which  have  been  thrown  off  by  the  in- 
flammatory process.  The  obstructing  mass  is  an  aggregation 
of  these  cells,  and,  though  easily  penetrated  by  any  instru- 
ment, which  may  remove  a  considerable  quantity  each  time 
it  is  inserted,  is  very  difficult  to  remove  completely.  Even 
when  the  fundus  seems  entirely  clear  we  often  find,  in  at- 
tempting to  dry  the  parts  perfectly,  that  the  cotton  pledget 
brino-s  away  more  of  these  white  scales,  so  that  the  complete 
clearing  out  of  the  meatus  is  a  matter  of  no  small  diflficulty. 
The  entire  epithelial  plug  presents  an  appearance  not  unlike 
a  wad  of  unsized  paper  that  has  been  moistened  in  water,  and, 
in  fact,  is  often  mistaken  for  a  foreign  body  of  this  kind,  which 
has  found  its  way  into  the  canal. 

Where  the  inflammation  is  of  what  may  be  called  the 
symptomatic  tvpe — that  is,  merely  an  indication  of  a  deeper- 
seated  intlaminatorv  process  within  the  mastoid — we  usuall)'^ 
fmd  that  tiic  superior  and  posterior  walls  of  the  canal  close  to 
the  membrana  tympani  are  most  involved.  The  canal  lumen 
at  its  deepest  part  is  narrowed  by  an  apparent  sinking  of  the 
walls,  and  at  the  fundus,  instead  of  a  well-defined  line  of  de- 
marcation between  the  drum  membrane  and  canal  walls,  it  ap- 
pears as  if  the  superior  and  inferior  walls  were  separated  only 
by  a  narrow  slit,  through  which  a  small  area  of  the  membrane 
is  seen.  The  chief  point  of  diagnostic  importance  is  the  dif- 
ference between  this  condition  and  that  seen  in  circumscribed 
otitis  externa.  In  this  latter  form,  after  the  speculum  has  been 
introduced  into  the  canal,  the  membrana  tympani  is  distinctly 
seen,  and  appears  normal  in  extent  as  the  obstruction  lies  near 
the  orifice  of  the  meatus.  In  the  disease  under  consideration 
the  introduction  of  the  speculum  is  easy,  but  the  canal  be- 
comes more  obstructed  as  we  approach  the  fundus,  owing  to 
the  fact  that  the  disease  is  a  periostitis  of  the  deeper  part  of 
the  canal  (Fig.  78).  It  is  of  extreme  importance,  especially  in 
children,  to  recognize  this  condition  early,  as  it  is  one  of  the 
best  indications  that  a  previously  existing  middle-ear  inflam- 
mation has  involved  the  deeper  structures,  or  that  an  accumu- 
lation of  pus  in  the  tympanum  has  passed  out  through  the 
Rivinian  fissure  along  the  superior  and  posterior  aspects  of 
the   meatus  (Fig.   Sj).      In   either   case   the   condition   is   one 


PROGNOSIS. 


249 


which  requires  prompt  treatment  in  order  that  serious  con- 
sequences mav  be  averted.  The  apj^earancc  j^resentcd  by  a 
chronic  diffuse  otitis,  resulting  in  either  uniform  narrowing  of 
the  meatus  or  isohited  bony 
deposits  or  exostoses,  offers 
no  ditiicultics  in  diagnosis. 
When  the  hitter  condition  is 
|iresent.  care  need  oidv  be 
taken  to  so  cleanse  the  j)arts 
that  the  observer  mav  be  cer- 
tain that  the  localized  en- 
croachment uj)on  the  lumen 
of  the  canal  is  beneath  the 
integument  instead  of  super- 
ficial to  it.  It  would  seem  al- 
most impossible  for  this  mis- 
take to  be  made,  but  masses  of 
hardened  cerumen  occasion- 
allv  j)resent  the  appearance 
of  an  exostosis,  the  surface  of 
which  is  covered  b\-  a  thin 
la\er  of  cerumen.  ll\  mians 
of  the  curette  any  foreign  substance  is  easily  removed  from  the 
canal  wall,  ami  the  true  condition  becomes  a|)[)arent  at  once. 

Prognosis. — The  course  pursued  by  the  disease  we  are 
here  considering  is  as  varied  as  tiie  causes  which  underlie  it. 
The  simj)ler  varieties  are  unattended  bv  anv  grave  results,  al- 
though somewhat  obstinate  to  relieve.  Where  the  deej)er 
|)arts  aie  involved,  where  the  disease  is  of  long  standing,  or 
where  the  condition  is  svmptomatic.  the  prognosis  is  frc- 
(pientlv  grave.  Im|K)rtant  regions  may  suffer  secondarily, 
bv  extension  directlv  from  the  canal,  or  the  condition  with- 
in the  meatus  may.  if  unchecked.  s[)rcad  to  the  middle  ear 
and  result  in  anv  of  the  sequela;  of  asevere  inffammation  with- 
in the  tvmj)anum.  Where  the  disease  is  secondary  to  an  in- 
tratvmpanic  affection  the  gravitv  of  the  prognosis  depends 
more  upon  the  condition  of  the  middle  ear  than  upon  the 
changes  within  the  canal.  As  regards  the  impairment  of 
function,  the  power  of  audition  may  suffer  either  from  the 
narrowing  of  the  meatus  throughout  its  entire  extent  or  by 
the  develojiment  of  circumscribed  bony  deposits.  In  some 
instances    the    chronic    congestion   of   the   deeper   structures 


Fig.  S7. — Appearance  observed  in  infancy 
wlicn  fluid  fmm  tlio  tynip.nnuni  esc.ipcs 
throujjh  the  kivinian  lissurc.  (Nat- 
ural .size.) 


250  DIFFUSE    EXTERNAL   OTITIS. 

caused  b}'  a  chronic  inflammatory  process  within  the  mea- 
tus, may  lead  to  functional  impairment.  In  the  descpiama- 
tive  form  of  inflammation  the  pressure  exerted  by  a  mass  of 
epithelium  may  produce  fatal  results  by  absorption  of  the 
bony  walls  and  exposure  of  the  cranial  contents.  This  may 
occur  without  any  symptoms  of  middle-ear  inflammarion,  or 
the  membrana  tvmpani  may  be  destroyed  and  a  suppurative 
otitis  media  result.  Sometimes  the  mass,  while  not  leading  to 
such  grave  results,  seriously  impairs  the  function  of  the  ear 
by  chronic  adhesive  processes  within  the  tvmpanum  from  the 
long-continued  pressure.  In  other  cases  the  pressure  causes 
labyrinthine  changes. 

Treatment. — In  the  mild  cases  of  chronic  diffuse  otitis 
externa  treatment  is  largely  directed  to  the  relief  of  the  dis- 
tressing pruritus  from  which  the  patient  suffers.  The  crusts 
arising  cither  from  involvement  of  the  sebaceous  glands  in 
seborrhcea  or  from  cutaneous  infiltration  in  eczema  should 
be  removed  by  some  bland  oily  application,  such  as  vaseline 
or  olive  oil,  after  which,  in  the  glandular  variety  of  the  dis- 
ease, it  will  be  sufficient  to  apply  once  each  dav  a  slightly 
stimulating  ointment,  such  as  the  unguent,  hvdrarg.  ammoniat., 
diluted  with  ten  parts  of  vaseline  or  cold  cream,  or  the  un- 
guent, hvdrarg.  oxidi  flavi  mav  be  employed  in  about  tlie 
saiTje  strength.  In  eczema  the  various  measures  detailed 
under  eczema  of  the  auricle  will  be  found  valuable.  It  is  im- 
portant, in  order  that  the  treatment  may  be  eflficacious,  that 
the  patient  should  refrain  from  scratching  the  ears,  as  this 
increases  the  local  inflammation.  For  this  purpose  we  may 
add  either  cocaine  or  morphine  to  the  above  ointments.  It 
is  well  for  these  patients  on  retiring  to  insert  into  the  ear  a 
pledget  of  cotton  smeared  with  such  an  ointment,  as  they 
frequently  injure  the  parts  during  sleep.  The  use  of  water  in 
any  inflammatory  condition  of  the  canal  attended  with  infil- 
tration of  the  integument  is  to  be  absolutely  forbidden,  as  it 
tends  to  increase  its  activity. 

In  the  parasitic  variety  the  fungus  should  be  removed  as 
completely  as  possible  by  means  of  the  curette,  forceps  and 
cotton  pledget,  great  care  being  taken  to  avoid  abrading  the 
epidermis  of  the  canal.  In  these  cases  the  walls  of  the  mea- 
tus will  be  found  very  sensitive,  and  the  complete  removal  of 
the  parasite  will  be  difficult.  The  occasional  application  of  a 
ten  per  cent,  solution  of  cocaine  during  the  operation  will  af- 


TREATMENT. 


251 


ford  considerable  relief  and  will  facilitate  the  operation.  It 
is  not  well  to  prolon^f  undulv  our  elTorts  at  removal  or  to  in- 
flict severe  pain.  After  as  much  as  possible  has  been  removed 
a  solution  of  bichloride  of  mercurv,  one  to  eight  thousand,  in 
fifty  per  cent  alcohol,  or  a  saturated  alcoholic  solution  of  bo- 
racic  acid,  or  a  two-pcr-cent  alcoholic  solution  of  salicvlic 
acid,  as  Siebenmann*  recommends,  should  be  applied  to  the 
])arts  bv  means  of  the  cotton  pledget. 

It  is  sometimes  well  to  employ  a  powder  instead  of  the 
above  solutions.  The  walls  of  the  canal  mav  be  lightlv  dusted 
with  boracic  acid  or  a  mixture  of  boracic  acid  and  salicylic 
acid  in  the  proportion  of  twentv  to  one.  In  this  wav  we 
avoid  the  presence  t)l  moisture,  a  condition  which  we  know 
faNors  the  grcjwth  of  tiic  fungus.  It  is  well  to  see  the  patient 
dailv  at  first,  and  at  each  sitting  to  remove  as  much  of  the 
deposit  as  possible.  When  the  canal  seems  free  the  antisep- 
tic solution  should  be  placed  in  the  hands  of  the  patient,  and 
he  slunikl  be  directed  to  instill  ten  or  twelve  drops  of  either 
])reparation  into  the  canal  twice  or  three  times  daily.  By 
this  means  anv  new  growth  is  prevented  and  a  complete  cure 
efTected.  Remembering  that  an  otomvcosis  is  often  depend- 
ent upon  a  suppurative  intlammation  of  the  middle  ear.  it  is 
scarcelv  necessary  to  state  that  this  affection,  if  present,  must 
be  treated  j)roperlv  in  order  to  prevent  the  recurrence  of  the 
condition. 

Prophylactic  measures  against  development  of  organisms 
within  the  meatus  should  be  taken  in  all  cases  of  aural  disease 
which  come  under  the  observation  of  the  surgeon.  A  com- 
mon cause  of  the  milder  varieties  of  this  affection  depends 
upon  a  habit  so  common  among  the  laity  of  instilling  oily  so- 
lutions into  the  ear  for  the  relief  of  pain.  Not  only  should 
this  be  forbidden,  but  the  surgeon  should  be  {)articularly  care- 
ful in  cases  where  it  is  necessary  to  use  oily  substances  within 
the  meatus  that  none  of  the  fatty  material  remains  in  the  canal 
when  the  patient  is  discharged.  To  be  certain  of  this  it  is  ad- 
visable u})on  dismissing  the  patient  to  wipe  the  canal  thor- 
oughly with  a  cotton  jiledgct  moistened  in  alcohol. 

In  the  desquamative  form,  the  first  indication  is  to  remove 
the  mass  of  epithelium  filling  the  canal.  This  is  by  no  means 
simple  where  the  disease  has  persisted  for  a  long  time,  espe- 

*  Arch,  of  Otol.,  vol.  xviii,  p.  235. 


2;2 


DIFFUSE    EXTERNAL   OTITIS. 


ciallv  as  attention  is  frequently  drawn  to  the  condition  for  the 
first  time  by  an  acute  inflammation  of  the  parts,  rcsultini^  in 
so  much  swelling  that  the  calibre  of  the  canal  is  greatly 
reduced. 

Our  first  efforts  at  removal  should  be  by  the  use  of  a  warm 
antiseptic  solution  injected  into  the  ear  by  means  of  the  syringe. 
This  will  usually  bring  away  the  superficial  portion  of  the 
mass,  and  occasionally  all  of  it.  Frequently,  however,  the 
deeper  portion  of  the  canal  remains  obstructed,  and  it  will  be 
necessary  to  use  the  blunt  curette  in  order  completely  to  re- 
move the  collection.  When  the  canal  is  swollen  and  tender, 
as  frequentlv  occurs  from  an  acute  exacerbation,  the  manipu- 
lation is  extremely  difficult,  and  sometimes  a  general  ana:?s- 
thetic  is  necessary.  In  using  the  curette,  we  should  first  at- 
tempt to  separate  the  mass  from  the  canal  along  one  wall, 
and  afterward  break  it  up  by  inserting  the  instrument  be- 
tween it  and  the  canal  wall  and  removing  small  portions  suc- 
cessivclv  until  a  narrow  channel  has  been  made  between  the 
canal  wall  and  the  foreign  bod  v.  Hv  directing  the  stream  of 
water  from  the  syringe  toward  this  channel,  the  entire  mass 
mav  usualh'  be  brought  awav,  although  it  mav  be  necessary 
to  remove  the  entire  collccti(jn  piecemeal  with  the  curette. 
If  it  is  impossible  to  insert  the  curette  between  the  ei)itlHlial 
aggregation  and  the  canal  wall  at  any  point,  owing  to  the  ten- 
derness of  the  meatus,  our  efforts  are  sometimes  more  success- 
ful if  a  passage  is  tunneled  directly  through  the  centre  of  the 
plug,  after  which,  by  carrying  the  curette  into  this  channel 
and  then  pressing  it  in  toward  the  opposite  wall  of  the  canal, 
the  portion  included  between  the  instrument  and  the  wall 
may  be  removed  ;  the  process  must  be  rejjcated  until  the  mea- 
tus is  perfectly  clear. 

Where  the  condition  has  remained  unrecognized  for  a  long 
time,  the  bony  meatus  close  to  the  drum  membrane  may  be 
very  much  dilated,  and  the  foreign  body  attain  such  dimen- 
sions as  to  render  its  removal  from  the  meatus  in  its  entirety 
impossible.  At  the  same  time  the  deep  meatus  has  been  so 
dilated  that  the  manipulation  of  an}^  instrument,  such  as  the 
curette  or  a  spoon,  is  very  much  restricted.  These  epithelial 
masses  may  invade  the  cells  of  the  mastoid  process  through 
the  absorption  or  necrosis  of  the  bony  walls  from  pressure. 
It  occasionally  becomes  necessary  to  open  the  mastoid  in 
order  completely  to  eradicate  the  disease.     Such  cases  have 


TRKATMIA'T  25^ 

been  reported,  but  an  element  of  tloubt  always  remains  as  to 
whether  thev  were  not  cases  of  cholesteatoma  oriirinatingf 
within  the  tvmpanum  and  invading  the  canal  secondarily. 

After  the  canal  has  been  thoroughly  cleared,  our  efforts 
should  next  be  directed  toward  putting  the  epidermis  in 
n(jrmal  conditicjn.  Here  powders  are  t)f  special  benefit,  as 
they  relieve  the  sodden  condition  of  the  parts  more  (juickly 
than  do  fluid  preparations.  For  this  purpose  boracic  acid 
may  be  dusted  over  the  walls  of  the  canal,  or  a  mixture  of 
boracic  acid  and  iodoform,  or  iodol.  if  the  odor  of  iodoform 
is  objectionable.  Ouite  recently  the  introduction  of  dermatol 
into  surgery  has  given  us  a  drug  particularly  adapted  to  these 
cases.  These  measures  should  not  be  trusted  to  the  hands 
of  the  patient,  but  should  be  carried  out  by  the  surgeon — at 
hrst  daily,  the  interval  being  increased  as  the  case  progresses, 
rhe  oxide  of  zinc  mixed  with  boric  acid,  in  the  proportion 
of  one  part  of  oxide  of  zinc  to  two  of  boric  acid,  may  also 
be  used  with  advantage  in  the  milder  forms  of  the  disease. 
When  necrosis  has  occurred  it  will  first  be  necessary  to  re- 
move the  dead  bone,  after  which  the  case  may  be  managed 
on  general  surgical  principles.  It  granulation  tissue  develops, 
a  thorough  cleansing  of  the  j)arts  may  be  sulVicient  to  cause 
it  to  disappear;  if  large  in  amount,  it  should  be  removed 
by  means  of  the  cold  snare  or  destroyed  /'//  si/u  by  the  gaU 
vano-cautery,  nitrate  of  silver,  or  chromic  acid.  The  last 
agent  yields  better  results  and  is  more  easily  manijiulated 
than  the  others. 

Where  the  disease  is  (jf  the  symptomatic  \aricty  much 
more  energetic  measures  must  be  undertaken,  and  if  the  i)ain 
is  intense,  cold  applications  to  the  mastf)id  j)rocess  are  indi- 
cated. This  is  most  easily  efTected  by  using  the  Leiter  coil 
(Fig.  81)  or  the  aural  ice  bag  (Fig.  70).  The  local  abstrac- 
tion of  blood  by  means  of  the  artificial  leech  may  also  give 
relief  where  the  pain  is  very  severe.  It  is  to  be  applied  be- 
hind the  ear  over  the  mastoid  process,  since  the  symjjtomatic 
variety  is  indicative  of  the  fact  that  this  region  is  afTected. 
From  a  healthy  adult  from  two  to  four  ounces  of  blood  may 
be  removed  ;  and  in  the  very  early  stages  this  plan  of  local 
bloodletting,  followed  by  the  application  of  cold,  may  pre- 
vent further  progress.  If  this  fails,  or  if  the  condition  has 
advanced  too  far  to  be  aborted,  a  long  deep  incision  should 
be   made   throuirh   the    tumefied    tissues   which   are    seen    to 


254 


DIFFUSE    EXTERNAL   OTITIS. 


encroach  upon  the  lumen  of  the  canal  close  to  the  membrana 
tympani.  This  incision  completely  divides  the  soft  parts 
down  to  the  bone.  The  short  curved  bistoury  is  carried  into 
the  canal  as  far  as  the  drum  membrane,  and  is  plunged 
quickly  into  the  bulging-  supero-posterior  wall  until  the  point 
is  felt  to  impinge  upon  the  bone;  it  is  then  drawn  outward, 
the  point  still  being  pressed  firmly  upon  the  bone.  In  this 
way  the  periosteum  is  divided  and  tension  relieved.  The  in- 
cision should  not  be  less  than  half  an  inch  in  length,  and  may 
be  even  longer;  the  bleeding  is  vcrv  free,  a  fact  which  con- 
tributes largelv  to  the  benefit  derived.  It  is  to  be  borne  in 
mind  that  the  external  otitis  here  is  a  manifestation  of  an 
infiammatory  process  within  the  upper  part  of  the  tympanum 
itself.  We  are  therefore,  in  making  the  initial  puncture,  to 
carry  the  knife  upward,  backward,  and  inward  beyond  the 
inner  extrcmitv  of  the  bony  canal,  through  the  membrana 
flaccida,  into  the  tympanic  vault  (Fig.  87).  The  incision  is 
completed  in  the  manner  above  described  by  drawing  the 
knife  outward  along  the  supero-posterior  wall  of  the  meatus. 
In  this  way  the  mucous  folds  within  the  tvmpanum  are  di- 
vided, and  the  congestion  within  the  middle  ear  reduced. 
Where  the  tumefaction  in  the  canal  is  due  to  the  presence  of 
pus,  evacuation  through  the  meatus  is  not  sufficient,  and  it  is 
imperative  that  the  mastoid  cells  should  be  at  once  opened 
and  every  vestige  of  diseased  bone  removed. 

Where  the  inflammation  has  led  to  a  diminution  in  the 
calibre  of  the  meatus  through  hypertrophy  of  the  bony  walls, 
it  is  sometimes  necessary,  in  order  that  the  function  of  the 
organ  may  be  preserved,  to  attempt  a  restoration  of  the 
channel  to  its  normal  size.  When  a  very  small  passage  re- 
mains, gradual  dilatation,  if  systematically  carried  out  for  a 
long  time,  may  prove  satisfactory.  This  is  best  accomplished 
by  inserting  into  the  canal  a  small  aluminium  tube,  which  will 
just  pass  through  the  constriction.  The  jiatient  is  to  wear  this 
for  one  or  two  days,  when  it  is  to  be  removed  and  a  little 
larger  tube  inserted.  It  is  seldom  possible,  however,  to 
promise  that  the  tul^e  may  ever  be  dispensed  with  perma- 
nentl3%  for  when  it  is  removed  the  parts  very  quickly  resume 
their  original  position.  The  diameter  of  the  meatus  may  be 
very  considei"ably  increased  by  carrying  out  this  treatment, 
and  the  patient  should  learn  to  insert  the  tube  himself,  wear- 
ing it  durmg  the  day  and  removing  it  at  night.     Its  presence 


ACUTE    DIFFLSi;    I.X  IKRNAL    OTITIS.  255 

causes  no  inconvenience,  and  effectually  relieves  the  impair- 
ment of  hearinjs^  clue  to  the  diminished  size  of  the  passa^^e. 
I'omerov  has  suggested  the  use  of  small  rubber  tubes  stretched 
(»ver  a  silver  probe  to  enable  them  to  be  inserted  through  the 
stricture.  After  thcv  have  been  propcrlv  placed  the  probe  is 
withdrawn  and  the  tube  resumes  its  original  dimensi(jns,  thus 
exerting  bv  its  elasticity  a  constant  dilating  force  against  the 
surrounding  walls.  This  {>lan  has  proved  advantageous  in 
some  cases,  but  relapses  have  taken  place,  even  after  the  con- 
dition was  apj)arently  cured.  Where  the  channel  is  so  nar- 
low  that  only  a  fine  probe  can  be  passed,  and  the  use  of  a 
tube  is  imj)<)ssible.  it  is  well,  for  the  first  few  davs,  to  carry 
a  verv  small,  tightly  wound  pledget  t)f  cotton  through  the 
constriction  bv  means  of  the  forcej^s ;  this  cotton  jdedget  ab- 
sorbs moisture  from  the  walls  of  the  canal,  increases  in  size, 
and  dilates  the  passage  slightly.  In  this  way  sufficient  space 
may  be  gained  to  permit  the  insertion  of  a  small  tube,  after 
wliich  one  of  the  plans  already  described  may  be  carried  out. 
The  removal  of  any  portion  of  the  bony  wall  by  means  of 
cutting  instruments  is  seldom  attended  by  good  results  where 
the  narrowing  is  symmetrical.  If  the  passage  is  encroached 
upon  bv  an  exostosis,  this  may  be  removed.  This  condition 
u  ill  be  treated  in  a  later  chapter. 

AcuTK  Diffuse  External  Oiitis. 

JEtiology. — The  acute  form  of  the  disease  usually  occurs 
as  an  exacerbation  of  a  i»revious  chronic  condition  ;  occasion- 
ally, however,  it  presents  as  an  idioj>athic  disease,  either  from 
exj)osure  to  cold  or  as  a  complication  ol  some  j)rolound  con- 
stitutional infection,  as  epidemic  influenza,  scarlet  fever,  typhus 
and  typhoid  fevers,  etc.  The  most  frecpient  cause  is  a  puru- 
lent otitis  media,  the  tissues  of  the  canal  becoming  infected  By 
the  purulent  discharge  in  which  they  are  bathed.  This  last  va- 
riety does  not  include  those  cases  already  denominated  under 
the  term  symptomatic.  Injuries  of  the  canal  from  mechanical 
violence  or  from  the  action  of  the  potential  or  chemical  escha- 
rotic  agents  may  also  give  rise  to  an  acute  diffuse  inflamma- 
tion of  the  parts.  An  occasional  cause  is  the  occurrence  of  a 
furuncle  in  the  meatus,  the  condition  becoming  general  and 
involving  the  entire  canal  after  the  circumscribed  process  has 
fully  developed. 

Pathology. — The  changes  consist  in  a  diffuse  inflammation 


256  difpt:se  external  otitis. 

of  the  cellular  tissue  of  the  walls  of  the  meatus.  In  the  first 
stage  the  parts  are  intensely  congested,  after  which  there  is  a 
free  transudation  of  the  fluid  elements  of  the  blood,  causing 
oedema ;  the  interstices  between  the  connective-tissue  fibres 
become  infiltrated  with  new  cells,  and  if  allowed  to  continue 
unchecked  pus  formation  results.  It  is  seldom,  however,  that 
this  occurs,  as  relief  is  sought  before  this  stage  is  reached. 
The  tissues  break  down  in  this  region  at  a  vcrv  late  period, 
on  account  of  their  density  and  firmness,  and  remain  infiltrated 
for  a  long  period  before  local  necrosis  results. 

Symptomatology.  —  The  subjective  symptoms  are  pro- 
nounced and  succeed  each  other  rapidly.  The  first  sensation 
is  one  of  fullness  or  discomfort  in  the  canal,  quickly  followed 
by  intense  pain.  The  constitutional  disturbance  is  frequently 
quite  marked,  the  temperature  being  elevated  from  two  to 
three  degrees  above  normal ;  considerable  prostration  is  pres- 
ent ;  the  patient  suffers  from  headache,  loss  of  appetite,  and  all 
those  symptoms  indicative  of  an  inflammatory  process  in  dense 
cellular  tissue.  From  the  swelling  of  the  parts  the  meatus  is 
rapidly  occluded  and  the  function  of  audition  is  markedly  in- 
terfered with.  Subjective  noises  are  often  ])rcscnt,  but  the 
pain  is  so  severe  that  they  are  seldom  complained  of.  In  ad- 
dition to  the  spontaneous  pain  intense  pain  is  elicited  upon 
touching  the  auricle.  After  a  short  period  the  surrounding 
lymphatic  glands  may  become  infiltrated,  especially  those  ly- 
ing immediately  behind  and  below  the  auricle,  any  movement 
of  the  jaws  is  painful,  and  in  severe  cases  the  mouth  is  opened 
with  ditficultv. 

Diagnosis. — W'c  have  to  dilTcrcntiate  between  a  circum- 
scribed inflammation  of  the  meatus,  an  acute  affection  of  the 
middle  ear  and  mastoid,  and  the  disease  under  consideration. 
The  symptoms  complained  of  by  the  patient  do  not  differ,  ex- 
cept in  severity,  from  those  characteristic  of  the  circumscribed 
external  otitis.  The  constitutional  disturbance,  however,  is 
much  more  marked  and  the  progress  of  the  disease  more  rapid. 
The  insertic^n  of  the  speculum  ordinarily  causes  but  little 
pain  and  the  outer  third  of  the  meatus  is  often  found  to  be 
nearl}^  normal  in  size.  Deeper,  however,  the  lumen  is  much 
diminished,  the  encroachment  usually  being  from  the  supero- 
posterior  wall,  which  seems  to  project  downward  and  for- 
ward into  the  canal.  The  swelling  is  more  pronounced  as 
we  ap[iroach  the  fundus  and  a  considerable  portion  of  the 


DIAGNOSIS. 


257 


/ 


drum  membrane  is  hidden  from  view.  Where  the  membrana 
tympani  lies  very  oblicjuely  to  the  sujieriorand  posterior  walls 
it  aj)parently  mer^^es  intt)  these  without  any  line  of  demarca- 
tion. This  is  particularly  the  case  in  infants,  owing  to  the  ab- 
sence of  t!ie  bony  meatus  ;  in  the  adult,  however,  if  the  canal 
alone  is  involved  the  observer  recoijnizes  that  a  portion  of  the 
drum  membrane  is  concealed  from  view,  but  that  the  swollen 
wall  of  the  canal  is  not  continuous  with  the  membrana  tvm- 
pani  {Vig.  8S).  A  sulcus  can  be  recognized  between  the  mem- 
brana tvmpani  and  the  tumefaction.  In  very  severe  cases 
the  swelling  may  be  so  great  as  to  occlude  the  meatus  com- 
|)letelv,  the  oj)posite  walls  lying  in  contact.  The  surface  of 
the  tumefaction  is  slightly 
moist,  jnesenting  a  dead- 
white  CiAur,  due  to  the  local 
necrosis  of  the  superficial 
ej)ithelial  cells.  If  these  are 
wiped  away  the  surface  ap- 
pears reddened  and  moist. 
This  desquamation  of  the 
suj)erficial  cells  is  often  a 
verv  |)r<)minent  feature  of 
the  disease  antl  mav  render 
the  diagnosis  extrenielv  dif- 
ficult. These  cells,  as  thev 
are  rapidh"  cast  off,  accumu- 
late in  the  canal  and.  owing 
to  its  contracted  calibre,  are 
with  great  difTiculty  cleared  away  so  as  to  permit  a  view  of 
the  small  portion  of  the  drum  membrane  not  hidden  bv  the 
swollen  canal  wall.  The  swelling  is  intensely  painful  to  ma- 
nipulation with  the  [»robe ;  pressure  in  front  of  the  tragus  or 
efforts  at  crowding  the  canal  upward  or  forward  are  attended 
with  s:vere  pain.  There  may  be  considerable  cedema  over  the 
post-auricular  region,  and  the  auricle  may  be  displaced  out- 
ward and  forward  from  the  side  of  the  head  more  or  less 
promincntlv.  Palpation  along  the  anterior  border  of  the 
sterno-mastoid  muscle  reveals  considerable  infiltration  of  the 
Ivmphatic  glands.  When  this  condition  occurs  with  cedema 
over  the  mastoid  the  differential  diagnosis  between  diffuse  ex- 
ternal otitis  and  perforation  at  the  tip  of  the  mastoid  is  possi- 
ble only  by  speculum  examination  alone.  It  is  exceeding!}' 
13' 


Fig.  88. — Acute  diffuse  external  otitis,  i»- 
voivinfj  pdstcro  -  supciior  canal  wall. 
(Natural  bi/.c.) 


258  DIFFUSE   EXTERNAL   OTITIS. 

important  in  these  cases  to  prolong  the  speculum  examination 
sufficiently  to  determine  the  coexistence  of  anv  inflammatorv 
condition  within  the  tympanum.  This  is  particularly  true  in 
the  case  of  children,  since  an  acute  purulent  otitis  media,  if 
severe,  may  be  accompanied  by  a  diffuse  inflammation  in  the 
external  meatus,  and  the  early  recognition  of  the  true  nature 
of  the  disease  is  a  matter  of  great  importance.  The  surgeon 
should  therefore  obtain  a  view  of  the  drum  membrane,  al- 
though this  may  require  considerable  time  and  inflict  a  certain 
amount  of  suffering  upon  the  patient.  Where  the  parts  are 
very  much  swollen  and  the  view  is  obstructed  bv  desquamated 
epithelium,  the  persistent  use  of  small  cotton-tipped  probes 
will  enable  us  to  clear  this  away,  and  to  reduce  the  swelling 
by  pressure  sufficiently  to  permit  an  inspection  of  the  drum 
membrane,  or  at  least  of  a  portion  of  it.  If  this  is  normal  in 
C()l(jr  we  are  warranted  in  the  assumption  that  the  disease  is 
confined  to  the  canal  alone. 

Prognosis. — The  progress  of  the  affection  will  depend 
largely  uj)()n  the  causation.  If  it  is  idiopathic  the  prognosis 
is  good  ;  if  dependent  upon  traumatism,  either  mechanical, 
chemical,  or  thermal,  the  outcome  will  depend  upon  the  se- 
verity of  the  injury  inflicted.  As  complicating  an  acute  or 
chronic  process  within  the  middle  ear  the  severity  of  the  lesion 
within  the  tympanum  furnishes  an  index  of  the  probable  out- 
come of  the  case.  When  arising  from  a  previous  chronic  in- 
flammation of  the  canal  witht)ut  any  special  exciting  cause,  the 
disease  is  usually  mild  in  character.  The  degree  of  constitu- 
tional disturbance  docs  not  indicate  the  probable  severity  of 
the  attack,  as  in  the  early  stages  ;  the  general  symptoms  are 
usualh-  vviv  well  marked  even  in  mild  cases. 

Treatment. — The  first  efforts  should  be  directed  toward 
relieving  the  severe  pain  which  the  patient  suffers,  and  the 
attempt  should  be  made  possible  to  abort  the  process  before 
the  stage  of  pus  formation  is  reached.  For  the  relief  of  pain, 
both  local  and  general  measures  are  indicated.  A  sufficiently 
large  dose  of  morphine  or  some  preparation  of  opium  should 
be  administered,  either  by  the  mouth  or,  if  the  severity  of  the 
attack  demands  it,  by  the  hypodermic  method.  The  patient 
should  be  confined  to  bed  and  kept  as  quiet  as  possible;  it  is 
also  well  to  obtain  a  certain  amount  of  revulsive  action  by 
the  administration  of  a  saline  cathartic.  If  seen  very  early, 
we  may  resort  to  local  bloodletting,  removing,  bv  means  of 


TREATMENT. 


259 


the  artificial  leech,  not  less  than  two  ounces  of  blood.  The 
site  from  which  this  is  removed  will  depend  somewhat  upon 
the  regi(jn  in  which  the  process  seems  to  be  most  severe,  but 
as  a  rule  in  the  diffuse  form  of  inflanunation  the  best  results 
are  obtained  by  the  abstraction  of  blood  from  the  mastoid 
region ;  here  preference  should  be  given  to  the  artificial 
leach  rather  than  to  the  natural.  Imtnediatciv  after  the  ab- 
straction of  blood  tlie  Leiter  coil  should  be  aj>plied  to  the 
mastoid  region,  or  the  aural  ice  bag  mav  be  used  if  this  is 
more  agreeable  to  the  i»ati(.-nt.  It  lor  auv  reason  local  de- 
pletion seems  inadvisable,  we  mav  proceed  at  once  to  apply 
the  ice  coil  or  ice  bag.  In  acklition  to  this,  considerable  re- 
lief is  often  obtained  by  fre(juently  irrigating  the  canal  bv 
means  of  the  ear  syringe,  or,  better,  bv  emploving  the  foun- 
tain syringe.  A  weak  antiseptic  solution,  as  of  bichloride  of 
mercury,  one  to  eight  thousand,  or  a  saturated  aqueous  solu- 
tion  of  boric  acid,  is  to  be  used  for  this  purpose.  The  warm 
lluid  should  be  allowed  to  How  into  the  meatus  for  a  period 
ot  from  live  to  fifteen  minutes,  according  to  the  relief  which 
it  affords.  In  this  manner  the  parts  arc  cleansed  and  the 
analgesic  effect  of  the  warm  douche  obtained.  It  is  not  neces- 
sary to  remove  the  ice  coil  from  the  mastoid  region  in  order 
to  carry  out  this  measure,  and  although  the  two  would  seem 
to  be  apparently  oj)i)osite  in  action,  the  effect  obtained  is 
otten  very  satisfactory.  This  plan  of  treatment  should  not 
be  persisted  in  for  more  than  twenty-four  hours,  at  the  end 
of  which  time,  if  the  svmj)toms  are  not  so  much  relieved  that 
the  patient  is  able  to  rest  without  the  use  of  an  opiate,  and 
comi)laiiis  ol  but  little  or  no  S|)ontaneous  pain,  more  active 
measures  are  demanded.  At  this  [)eri(Kl  no  treatment,  to  my 
mind,  is  so  efficacious  as  a  dee[)  free  incision  in  the  canal, 
relieving  at  the  same  time  tiie  tension  of  the  parts  and  effect- 
ing l(jcal  depletion.  In  order  to  be  efficacious,  the  incision 
should  be  deep  and  of  considerable  length.  The  site  of  elec- 
tion is  usually  the  posterior  or  postero-superior  wall  of  the 
canal.  Under  illuminati<in  by  means  of  the  head  mirror,  a 
sharp  stout  knife,  such  as  is  shown  in  Fig.  87,  should  be  carried 
tiirough  the  swollen  canal  wall,  close  to  the  drum  membrane, 
imtil  the  p(jint  of  the  instrument  is  felt  to  imj)inge  upon  the 
bone.  The  incision  is  then  extended  directly  outward  for 
from  one  half  to  three  fourths  of  an  inch,  dividing  all  the  over- 
lying structures,  the  point  of  the  knife  being  kept  in  contact 


26o  DIFFUSE   EXTERNAL   OTITIS. 

with  the  bone  throughout  the  entire  length  of  the  incision. 
Although  intensely  painful,  the  relief  afforded  is  almost  im- 
mediate, and  is  complete  usually  at  the  end  of  twelve  hours. 
Hartmann  *  strongly  advises  against  incision  in  tiie  acute 
form  of  diffuse  external  otitis,  asserting  that  improvement 
never  follows  the  procedure,  while  frequently  the  condition 
is  much  aggravated.  Certainly  this  has  not  been  my  experi- 
ence, although  I  hesitate  to  differ  with  so  high  an  authority. 
The  only  possibility  of  this  measui'e  inflicting  injury  would  be, 
it  seems  to  me,  in  cases  where  the  field  of  operation  had  not 
been  properly  cleansed.  If  the  canal  is  freely  irrigated  before 
the  incision  is  made  1  can  see  no  reason  why  the  result  should 
be  anything  but  satisfactory.  After  the  operation  the  ear  is 
to  be  syringed  every  two  to  four  hours  with  a  mild  antiseptic 
solution.  This  irrigation  is  to  be  continued  until  the  local 
condition  becomes  normal,  the  frequency  being  diminished 
gradually.  Complete  resolution  with  restoration  of  the  nor- 
mal calibre  of  the  canal  is  frequently  rather  slow,  and  may 
not  occur  for  several  weeks.  During  this  period  the  canal 
is  apt  to  be  the  seat  of  a  desquamative  inflammation,  the  epi- 
thelium being  rapidly  thrown  off,  while  at  the  same  time  a 
certain  amount  ot  serous  transudation  takes  place,  causing  a 
thin  turbid  discharge  from  the  canal,  in  this  condition  the 
meatus  offers  a  fayt)rable  site  for  the  development  of  asper- 
gillus,  and  our  efforts  at  cleansing  the  parts  should  not  cease 
until  the  discharge  has  entirely  disappeared.  For  the  first 
few  days  the  most  relief  will  be  obtained  by  the  use  of  one 
of  the  antiseptic  solutions,  the  canal  being  cleansed  from  two 
to  four  times  daily,  according  to  the  amount  of  discharge. 
After  the  discharge  has  ceased  the  use  of  any  fluid  in  the 
canal  rather  prolongs  the  process,  and  the  parts  will  more 
quickly  return  to  their  normal  condition  it  ihe  walls  of  the 
meatus  are  dusted  lightly  with  some  antisejitic  or  astringent 
powder,  such  as  finely  divided  boric  acid,  oxide  of  zmc.  der- 
matol,  bismuth  subnitrale,  or  any  similar  substance.  II  it  is 
necessary  to  leave  the  treatment  largely  to  the  hands  of  the 
patient,  alcoholic  solutions  may  be  used  in  place  of  powders. 
Of  tliese,  a  four-  or  eight-per-cent  solution  of  boric  acid  in 
dilute  alcohol  is  probably  the  most  efficacious.  If  the  dis- 
charge continues,  after   the    use  of  the    powders   and    upon 

*Krankhcitcn  des  Ohres,  Berlin,  1S89,  p.  99. 


CROUPOUS    AND    DITHTHKRITIC    EXTERNAL    OTITIS.    261 

thorouf^hlv  drviiiij^  the  car  by  means  of  the  cotton  pledget, 
we  find  that  the  cutaneous  surface  is  reddened  and  moist,  a 
stimulating  apj)lication,  such  as  a  solution  of  nitrate  of  silver, 
lii^htlv  brushed  over  the  canal  will  frequently  cause  the  walls 
to  return  rapidly  to  their  normal  condition.  In  makin*^  these 
applications  a  comparativelv  mild  solution  (about  ten  grains 
to  the  ounce)  should  be  used  at  first,  the  strength  being  grad- 
uallv  increased  according  to  the  indications.  These  applica- 
tions may  at  first  be  made  daily,  and  afterward  at  longer  inter- 
vals, h  the  disease  is  not  seen  in  itsearlv  stages  and.  in  spite 
ol  our  ctTorts.  there  is  considerable  destruction  of  tissue,  the 
affection  may  result  in  a  perichondritis  of  the  auiicle,  with 
partial  necrosis  of  the  cartilaginous  framework.  The  treat- 
ment of  this  affection  has  ahead v  been  considered,  if  our 
efforts  to  limit  the  pathological  j)iocess  to  the  soft  parts  aie 
unsuccesstul  and  there  is  an  involvement  of  the  underlying 
osseous  structures,  the  case  is  to  be  dealt  with  according  to 
the  rules  laid  down  for  the  management  of  acute  iiiflamma- 
tion  ol  the  mastoid  j)rocess. 

In  every  case  of  acute  inflammation  of  the  external 
meatus  it  is  to  be  remembered  that  so  long  as  we  conhne  the 
process  to  the  canal  walls  we  have  an  affection,  the  manage- 
ment of  which  is  comj>arativelv  simple.  The  danger  is  that 
it  may  either  extend  to  the  bonv  or  cartilaginous  structures, 
on  one  hand,  or  mav  involve  the  tympanic  cavity  secondarily, 
in  which  case  we  have  to  deal  with  a  sujipurative  process 
w  ithin  the  middle  ear.  Moreover,  where  extension  to  the 
t\  tni»anum  occurs,  it  is  the  upper  part  of  the  cavity  which  is 
involved.  As  this  portion  of  the  tympanum  is  richly  sup- 
plic(l  witli  celluL'ir  tissue,  the  comj^lication  constitutes  a  men- 
ace to  lite. 

Croupous  and  Dh'iitiikritk    Extprn.m.  Otitis. 

The  diseases  included  imder  the  above  heading  constitute, 
in  reality,  but  minor  subdivisions  of  diffuse  external  otitis. 
Since  the  epidermis  covering  the  meatus  differs  in  no  respect 
from  that  covering  other  portions  of  the  body,  we  have  no 
reason  to  presume  that  it  should  be  exempt  from  the  above 
special  types  of  inflammation.  Under  favorable  conditions 
the  germ  either  of  croupous  or  of  diphtheritic  inflammation 
may  find  lodgment  within  the  meatus  and  produce  there  its 
characteristic  exudation.     The   croupous  form   is   less   com- 


262  DIFFUSE    EXTERNAL   OTITIS. 

monly  observed  than  the  diphtheritic.  Like  a  croupous  in- 
flammation in  other  portions  of  the  bodv,  it  is  characterized 
by  a  white,  thick,  velvety  deposit  on  the  surface  of  the  mem- 
brane involved,  consisting  of  coagulated  fibrin  containing 
within  its  meshes  white  blood  corpuscles.  This  deposit  lies 
immediatelv  upon  the  surface,  and  can  be  detached  from  the 
underlying  structures  without  the  rupture  of  blood  vessels. 
It  is  probable  that  certain  conditions  of  the  general  health 
render  the  patient  particularly  prone  to  this  form  of  inflam- 
mation. Tiie  condition  known  as  hvperinosis,  or  an  increase 
in  the  hhiiii  elements  in  the  blood,  is  undoubtcdlv  the  chief 
predisposing  factor.  Given  this  general  condition,  and  a 
simple  inflammation  of  the  epidermis  lining  the  meatus,  the 
lodgment  of  the  specific  germ  of  croupous  inflammation  w  ill 
ordinarilv  be  followed  bv  a  change  fri)m  the  simple  type  to 
the  croupous  form. 

The  diphtheritic  form,  on  the  contrarv.  is  most  frequently 
observed  as  a  comj)lication  of  otitis  media,  dej)endent  upon 
either  a  diphtheritic  inflammation  of  the  fauces  or  the  angina 
of  scarlatina,  although  it  occasionally  occurs  as  a  primary 
affection.  When  occurring  as  a  complicating  lesi(5n,  the 
source  of  infection  is  usually  the  middle  ear;  a  purulent  in- 
flammation here,  with  subsequent  rupture  of  the  membrana 
tympani,  being  followed  by  a  purulent  discharge  which  con- 
tains the  specific  diphtheritic  germ.  Such  an  otitis  media  is 
accoinpanied  by  a  diffuse  external  otitis  in  most  cases.  The 
external  meatus  is  therefore  in  a  condition  favorable  to  the 
lodgment  and  development  of  the  diphtheritic  germ. 

The  [)hysical  examination  reveals,  in  the  early  stages,  the 
walls  of  the  meatus  covered  with  a  white  deposit,  or,  if  ob- 
served only  in  the  period  of  necrosis,  with  a  gravish-white 
membrane,  which  is  firmly  attached  to  the  underlying  skin, 
and  can  be  removed  only  bv  the  use  of  considerable  force,  the 
removal  being  attended  with  the  rupture  of  blood  vessels. 
When  spontaneous  exfoliation  has  taken  place,  the  exposed 
areas  show  a  loss  not  only  of  the  superficial  epithelium,  but 
also  of  the  deeper  layers,  the  condition  being  one  of  true 
ulceration.  The  fibrous  structures  of  the  cutis  are  also  aflect- 
ed,  becoming  swollen  and  encroaching  markedly  upon  the 
lumen  of  the  passage.  The  condition,  whether  of  primary  or 
secondary  origin,  presents  the  same  picture,  and  its  recogni- 
tion is  not  difficult.      It  might  be  confounded  with  croupous 


TRKATMKNT.  263 

inflammation,  but  if  \vc  bear  in  mind  that  a  croupous  deposit 
separates  from  the  underlx  intj  parts  without  hasmorrhage,  the 
mistake  need  not  be  made.  The  severe  type  of  desquamative 
inflammation  of  the  canal,  either  occurring  primarily  or  de- 
pendent upon  an  otitis  media  purulenta,  mav  also  lead  to 
error.  Here,  however,  the  deposit  is  not  membranous,  but 
consists  simply  of  necrotic  epithelial  cells  suj)erimposed  upon 
each  other.  There  is  no  destruction  of  tissue,  and  upon  re- 
moval no  ulceration  remains.  In  the  same  wav  an  asj)erj^illus 
w-ithin  the  canal  mav  be  mistaken  for  a  diphtheritic  iiitlam- 
mation,  but  the  microscope  will  easily  reveal  the  true  ciiarac- 
ter  of  the  disease.  The  history  of  the  case  will  also  enable  a 
dilTerentiation  to  be  made  between  the  various  conditions. 

The  presence  of  a  croupous  or  diphtheritic  deposit  in  the 
external  canal,  when  occurring  as  a  secondary  disease,  is  u*^u- 
ally  no  serious  matter,  since  the  surface  |)resented  for  the 
absorj)tion  of  the  toxine  of  the  diphtheria  bacillus  is  one 
through  which  this  takes  place  very  slowly  ordinarily.  In 
cases  where  the  dij)htheritic  deposit  in  the  canal  is  but  a  sec- 
ondary feature  of  the  general  infection  the  outcome  depends 
upon  the  seveiity  of  the  origitual  disease  without  reference  to 
the  local  manifestation  in  the  auditory  meatus.  Occasionally 
suQh  deposits  occur  primarily,  tbe  germ  gaining  access  to  the 
external  canal  in  some  unknown  way,  and  taking  root  there 
upon  an  abrailed  surface  which  has  resulted  from  a  traumatic 
or  other  cause.  In  such  instances  only  very  slight  constitu- 
tional symptoms  are  a|)t  to  be  present,  and  the  danger  to  be 
feared  most  is  that  the  inflammation  of  the  external  canal  may 
extend  inward  and  involve  the  tympanum,  the  mucous  lining 
of  which  would  |)ermit  general  infection  more  easily  than 
wt)uld  cutaneous  lining  of  the  canal.  CVou|tous  deposits  are 
of  trivial  importance  aside  from  the  local  pain  which  is  pres- 
ent, and  this  is  no  more  severe  than  in  simple  diffuse  inllam- 
mation. 

Treatment. — The  treatment  of  the  local  conrlition  consists 
in  the  tliorough  and  frequent  cleansing  of  the  surlace  involved 
to  prevent  the  membrane  from  spreading  by  contiguity  of 
structure,  thus  increasing  the  extent  of  the  surface  through 
which  the  jioison  may  enter  the  circulation.  A  diphtheritic 
membrane  in  any  situation  will  be  exfoliated  spontaneously  at 
the  end  of  from  three  to  eight  days.  If  removed  by  violence 
before  this  time,  blood  vessels  are  opened,  and  the  raw  surface 


264  DIFFUSE    EXTERNAL   OTITIS. 

becomes  covered  very  quickly  by  a  new  deposit,  while  the 
laceration  of  the  vessels  rather  favors  the  absorption  of  tlie 
poison.  It  is  wise,  therefore,  to  confine  our  efforts  to  keeping 
the  parts  thoroughly  cleansed,  in  this  manner  diminishing  the 
activity  of  the  germ,  taking  care  that  our  efforts  are  not  so 
vigorous  as  to  excite  any  inflammatory  reaction  on  the  sur- 
rounding parts.  To  effect  a  thorough  cleansing  of  the  canal 
we  may  resort  to  the  use  of  the  ear  syringe,  or,  perhaps  bet- 
ter, the  fountain  syringe,  employing  a  solution  of  lime  water, 
which  is  allowed  to  flow  into  the  canal  for  from  five  to  ten 
minutes.  In  this  way  portions  of  the  deposit  already  necrotic 
are  removed,  and  a  certain  amount  of  solvent  action  is  exerted 
upon  the  transudation  which  is  still  firmly  attached  to  the 
parts  beneath.  Antiseptic  solutions  may  be  used  here,  the 
strength  of  the  solution  being  somewhat  greater  than  that 
employed  for  ordinary  cleansing  purposes.  In  this  way  the 
deposit  is  rendered  inert,  while  at  the  same  time,  by  its  pres- 
ence, it  protects  the  surface  to  which  it  is  attached,  and  when 
it  exfoliates  spontaneouslv  the  denuded  surfaces  are  protected 
by  the  presence  of  granulation  tissue,  which  offers  a  barrier 
to  local  infection. 

In  addition  to  irrigation,  certain  medicinal  preparations 
may  be  applied  to  the  deposit  by  means  of  the  cott(jn  ap{)lica- 
tor;  of  these,  I  think  the  solution  of  ferric  sulphate  in  the  full 
strength  is  bv  far  the  most  efficacious.  This  causes  a  rapid 
necrosis  of  the  superficial  layers  of  the  pscudo  membrane, 
while  at  the  same  time  it  exerts  no  irritating  action,  even  if 
it  touches  parts  which  have  not  yet  become  affected.  This 
local  necrosis  inhibits  or  stops  completely  the  growth  of 
the  germ,  putting  an  end  both  to  its  toxic  effect  upon  the 
general  system  and  to  its  further  local  propagation.  A  croup- 
ous exudate  may  be  managed  in  exactly  the  same  manner,  its 
separation  being  more  easily  effected  than  one  of  a  true  diph- 
theritic character.  In  this  form,  after  the  iron  solution  has  been 
applied,  it  is  often  possible  to  remove  a  considerable  portion 
of  the  deposit  by  means  of  the  forceps  without  inflicting  any 
injury  upon  the  cutaneous  lining  of  the  canal.  The  adminis- 
tration of  constitutional  remedies  will  be  governed  by  the 
same  rules  which  ap])lv  to  similar  deposits  located  in  the 
fauces.  Remembering  that  a  croupous  exudation  has  for  its 
predisposing  cause  a  certain  blood  condition,  it  is  wise  to  ad- 
minister the  tincture  of  the  chloride  of  irc>n  in  large  doses. 


H.-EMORRHAGIC    EXTKRX AL   OTITIS.  265 

with  the  hope  of  cutting  short  the  attack.  In  the  same  man- 
ner a  cli[)htheritic  membrane  appeariiiij:  in  the  meatus,  if  ac- 
comj)anie(l  bv  tlie  characteristic  constitutional  s\  niptoms  of 
septic  infection,  demands  the  free  use  of  stimulants  and  such 
drugs  as  mav  be  believed  to  mitigate  the  action  of  the  poison. 
The  various  local  complications  do  not  dilTer  from  tlui^e  al- 
readv  mentioned  under  acute  external  otitis. 

II.l.M()KKH.\(;iC    EXTKKNAl.   OlIIlS. 

Under  this  term  Polit/er*  has  described  a  disease  of  the 
external  auditory  meatus  characterized  bv  the  presence  of 
vesicles  upon  the  walls  of  the  canal.  The  inferior  and  anterior 
walls  are  usually  the  seat  of  the  manifestation,  although  the 
other  walls  are  occasionally  afTected.  These  vesicles  are  filled 
with  a  bloody  fluid,  and  if  allowed  to  remain,  disappear  spon- 
taneously at  the  end  of  a  few  davs.  their  site  bemg  marked  by 
an  excoriated  area. 

The  disease  ma\  ott  ui  eithir  as  a  primarv  affection  or  as 
a  comj)lication  of  an  acute  inllammatt)rv  j>rocess  within  the 
tympanum.  The  constitutional  svmptoms  are  verv  well 
marked,  and  consist  of  intense  local  pain,  which  frecpientlv 
assumes  a  neuralgic  character,  sjjreading  over  the  entire  side 
of  the  head  :  the  temperature  is  elevated  to  from  i)<)°  to  102°, 
and  there  is  a  marked  prostration  ;  occasionallv  delirium  is 
present.  The  occurrence  of  this  condition  in  the  severe  forms 
of  tvmpanic  inflammation  which  complicate  constitutional  dis- 
eases of  the  infectious  tvpe,  particularlv  epidemic  influenza, 
seems  to  show  that  the  condition  is  indicative  rather  of  a 
marked  general  infection  than  of  anv  distinct  local  patho- 
logical process.  In  cases  where  we  meet  with  this  form  of 
external  otitis  as  an  idioj^athic  disease,  I  am  luore  inclined  to 
consider  it  as  either  a  tropho-neurosis  similar  in  manv  re- 
spects to  herpes,  or,  if  the  deeper  lavcrs  of  the  canal  arc  in- 
volved, as  an  accidental  complication  of  a  simple  diffuse  otitis. 
The  latter  view  is  that  taken  bv  Gruber,t  and  this  seems  to  be 
entirely  tenable.  It  is  not  improbable  that  the  extravasation  of 
blood  cuts  short  the  inflammatorv  process  in  the  same  manner 
as  local  depletion  bv  artiticial  means,  when  the  above  measure 
is  employed  therapeuticallv  in  inflammation  of  the  canal. 


•  Lehrb.  der  Ohrenheilk.,  Stuttgart,  1893.  p.  154. 
t  Lehrb.  dcr  Ohrenheilk.,  Vienna,  i883,  p.  289. 


266  DIFFUSE    EXTERNAL    OTITIS. 

Treatment. — The  primary  indication  for  treatment  is  to 
relieve  the  constitutional  symptoms,  the  local  condition  being 
unimportant  and  recpiiring  but  little  attention.  The  intense 
suffering  must  be  relieved  by  the  administration  of  free  doses 
of  morphine  hvpodermically.  When  the  neurotic  symptoms 
are  well  maikcd  the  administration  of  bromide  of  sodium 
in  full  doses  will  do  much  to  render  the  patient  more  com- 
fortable. Complete  rest  should  be  insisted  upon.  The  diet 
of  the  patient  should  consist  mostly  of  fluids  for  the  hrst 
twenty-four  or  forty-eight  hours.  The  disturbance  of  the 
nervous  system  frequently  brings  about  severe  constipation, 
which  in  turn  increases  the  severity  of  the  local  pain.  It  is 
well,  therefore,  early  in  the  affection  to  administer  calomel  in 
small  repeated  doses  until  the  effect  upon  the  intestinal  canal 
is  obtained,  its  action  being  aided,  if  necessary,  by  a  saline 
cathartic.  Locally  very  little  need  be  done,  the  condition 
within  the  canal  being  kept  under  observation  in  order  that 
any  tendency  toward  inflammation  of  the  middle  ear  may  be 
readily  recognized  and  proper  measures  instituted  to  check  it. 
It  the  vesicles  are  of  considerable  size  thev  mav  be  opened 
with  a  delicate  knife,  the  walls  of  the  vesicles  being  jireserved 
as  much  as  possible  to  protect  the  denuded  areas  within  the 
canal.  In  case  of  spontaneous  rupture  the  site  of  the  vesicles 
may  be  lightly  dusted  with  zinc  oxide,  lycopodium,  bistnuth, 
or  any  bland  powder  which  will  protect  them  until  they  are 
covered  by  normal  epithelium.  Occasionally  these  vesicles 
are  located  upon  the  tympanic  membrane,  in  which  event  the 
pain  is  of  unusual  severity  and  the  constitutional  symptoms 
are  correspondingly  increased.  In  such  cases  it  is  wise  to 
open  the  vesicles  as  soon  as  thev  appear,  since  almost  imme- 
diate relief  follows.  Care  should  be  taken  that  the  canal  is 
in  a  thoroughly  aseptic  condition  before  the  operation,  and 
the  operator  should  guard  against  introducing  the  knife  too 
deeply  for  fear  of  wounding  the  deeper  lavers  of  the  drum 
membrane,  and  of  opening  into  the  tvmpanic  cavitv.  The 
local  tenderness  renders  manipulation  difficult,  and,  unless 
the  head  is  firmlv  held  bv  an  assistant,  either  of  the  above 
accidents  is  liable  to  occur.  The  sensitiveness  of  the  reofion 
may  be  reduced  somewhat  by  filling  th.e  canal  with  a  ten-per- 
cent aqueous  solution  of  cocaine  about  twentv  minutes  before 
the  operation  is  to  be  performed.  This  solution  must,  o/ 
course,  have  been  j)reviously  sterilized  liy  boiling. 


CIIAi*Ti:K    XIII. 

IMl'AC  Ti:i)    CKKIMIN. 

Willi  i:  constitutiiiLj  a  condition  which  differs  in  no  respect 
from  tliat  present  when  any  foreij:^n  body  is  present  in  the 
meatus,  this  disease  is  of  such  common  occurrence  that  it 
seems  wise  to  consider  it  under  a  separate  chapter. 

/Etiology. — The  causes  which  lead  to  this  condition  de- 
pend eiilier  upon  the  production  of  an  increased  amount  of 
the  normal  secretion  of  the  ceruminous  glands,  or  uixm  an 
interference  with  it^  regular  discharj^e  from  the  canal.  In 
health  cerumen  is  continually  formed  by  the  j^lands  found  in 
the  meatus,  and  is  discharj^ed  from  the  canal  constantly,  but 
in  such  small  quantities  that  its  |)resencc  is  unnoticed.  Any 
obstructive  conditit)n  interferini;  with  this  process  leads  to 
an  accumulation  of  the  secretion  within  the  meatus,  and  il  it 
exists  for  a  lonp:  period  of  time  a  considerable  mass  will  ac- 
cumulate, varying  in  size  and  density  accordinc^  to  the  activity 
of  the  secretory  process  and  the  lenjjth  of  time  that  the  ob- 
struction  has  existed.  The  conveyance  of  the  product  along 
the  meatus  is  effected  j)rincipally  by  the  acti(jn  of  the  jaws 
during  mastication  and  sj)eaking.  With  every  motion  at  the 
intermaxillarv  articulation  the  anterior  and  inferior  walls  of 
the  canal  are  moved,  on  account  of  the  intimate  relation  be- 
tween the  tragus  and  the  capsular  ligament  of  the  articulaticjn. 
This  motion,  when  the  canal  is  of  normal  size  and  shape,  acts 
in  such  a  manner  that  any  foreign  body  within  the  fibrous 
meatus  is  moved  constantly  toward  its  orifice.  If  the  canal 
presents  certains  anomalies  in  curvature  or  if  the  orifice  is 
very  narrow,  the  force  may  have  exactly  the  reverse  effect, 
and  any  body  lying  within  the  passage  may  be  carried  in  the 
opposite  direction — that  is,  deeper  and  deeper  into  the  canal 
toward  the  drum  membrane.  If  a  small  mass  of  cerumen 
collects  in  the  canal  its  mere  presence  causes  an  increased 
amount  of  secretion  from  the  glands  lying  in  the  immediate 

(267) 


263  IMPACTED    CERUMEN. 

vicinity,  while,  at  the  same  time,  it  acts  as  an  obstruction  to 
the  outward  passage  of  the  product  of  the  glands  lying  deeper 
within  the  channel. 

Although  the  causes  stated  are  those  most  frequently 
operative  in  the  production  of  the  impaction  of  cerumen,  it 
must  be  remembered  that  the  secretory  power  of  any  gland 
may  be  modified  by  interference  with  its  nerve  supply.  Under 
certain  conditions  we  are  warranted  in  considering  that  the 
disease  is  of  a  troj)ho-neurotic  character.  It  is  certain  that 
the  op[iositc  condition,  or  one  in  which  the  cerumen  is  dimin- 
ished in  quantity  is  frequentlv  encountered  in  proliferous  in- 
flammalioa  oi  the  middle  ear.  Prolitcrous  otitis  media  fre- 
quentlv depends  upon  some  perversion  of  the  troj)hic  nerve 
supply,  and  we  are  warranted  in  assuming  that  an  increased 
amount  of  cerumen  mav  occasionally  occur  from  tro{)ho- 
neurotic  causes. 

Pathology. — Upon  removal  of  these  masses  from  the  mea- 
tus they  are  found  to  contain  not  only  the  oily  substance  which 
is  normally  secreted  bv  the  parts,  but  also  certain  vegetable 
spores,  the  presence  of  which  is  purely  accidental.  The  mass 
is  occasionally  covered  by  desquamated  epithelium,  while  not 
infrequently  we  find  in  the  centre  a  foreign  body  which  has 
f(nmd  its  way  into  the  meatus  at  some  time  and  has  formed 
a  nucleus,  about  which  the  normal  secretion  has  collected. 

This  description  applies  to  the  simple  cases  of  impacted 
cerumen.  When,  however,  the  masses  attain  considerable 
size  the  pathological  process  is  more  complex,  and  there  is 
in  addition  a  chronic  desquamative  inflammation  of  the  deep 
canal  dependent  iij)on  the  presence  of  the  foreign  bod  v. 
For  the  same  reason  the  glands  are  probably  stimulated  to 
increased  activitv.  As  long  as  the  mass  consists  of  cerumen 
only,  no  considerable  changes  are  wrought  upon  the  b<iny 
walls  of  the  passage;  when  added  to  this,  however,  an  inflam- 
mation of  the  desquamative  tvpe  is  set  up  bv  the  presence  of 
this  foreign  body,  the  ossec^us  walls  mav  be  partiallv  de- 
stroyed or  the  deep  part  of  the  canal  may  be  enormously 
dilated.  This  is  especially  prone  to  take  place  in  the  region 
of  the  posterior  wall,  and  the  pneumatic  spaces  of  the  mastoid 
are  obliterated.  In  some  instances  a  chronic  osteitis  is  devel- 
oped by  the  pressure,  and  the  mastoid  cells  not  only  disap- 
pear, but  the  entire  process  becomes  sclerosed  and  of  ivory- 
like hardness.    The  membrana  tympani  may  be  perforated  by 


SYMPTOMATOLOGY.  269 

the  pressure,  and  the  removal  of  tlic  mass  mav  then  reveal 
extensive  patholojj^ical  clianj^es  within  the  middle  ear. 

Symptomatology. — The  svmptoms  dependent  ii]>on  the 
condition  vary  with  the  size  of  the  mass,  with  its  location,  and 
with  the  amount  of  secondarv  inllammation  which  its  presence 
has  excitetl.  The  lumen  of  the  meatus  may  be  encroached 
up(jn  to  a  considerable  extent  without  anv  nc^ticeable  impair- 
ment of  the  auditorv  function,  or  witjjout  the  aj)j>carance  of 
anv  subjective  svmptoms,  such  as  tinnitus,  autophonv,  or  a 
feelinj^  as  if  the  canal  were  stopjtctl.  On  the  other  hand,  a 
very  small  mass  mav  be  so  situated  as  to  ijive  rise  to  jiromi- 
nent  svm[)toms.  It  it  is  in  such  a  position  tiiat  the  membrana 
tympani  is  pressed  upon,  the  sidjjective  svmptoms  arc  apt  to 
occur  early,  and  the  function  of  the  or^an  may  be  ajipreci- 
ablv  interfered  w  ith,  even  thoujjh  tlie  mass  be  small.  A^ain, 
a  lar^e  collection  of  cerumen  mav  lie  in  the  cartiia}:jinous 
meatus  and  almost  completely  occlude  its  lumen  without 
causini^  any  symptoms  referable  to  the  ear.  Frequently  the 
first  intimation  of  any  trouble  will  be  the  occurrence  of  sud- 
den impairment  of  hearinjx  foUowiniif  a  phuifje  bath,  when, 
on  cominyf  out  of  the  water,  the  ear  feels  "stuffv"  and  full. 
These  sensations  are  at  first  attributeil  to  the  presence  of 
water  in  the  canal.  The  efforts  of  the  patient  to  remove 
this  failinij  to  relieve  the  discomfort,  he  seeks  advice,  and  an 
examination  reveals  the  presence  of  a  mass  which,  from  its 
size,  must  have  been  in  the  canal  for  a  considerable  period 
of  time.  The  sudden  access  ul  the  svmptoms  is  due  to  the 
displacement  of  the  pluij  bv  the  water  which  has  entered 
the  meatus,  causinc^  it  to  assume  a  |)osition  where  it  com- 
pletelv  obstructs  the  passae^e.  In  other  cases  the  patient  be- 
comes conscious  that  the  jtower  of  hearing-  is  gradually  but 
constantlv  diminishing  :  coexistent  with  this  impairment  f)f 
function  subjective  noists  make  their  aj>j>eaiance,  at  first 
causing  but  little  annoyance,  but  subsequently  becorninp^  so 
loud  and  persistent  as  to  cause  him  to  seek  relief.  Where 
the  occlusion  is  marked  the  patient  often  comjilains  of  au- 
tophonv, hearing  his  own  voice  as  if  it  came  from  within 
the  head.  This  svmptom  is  particularlv  marked  where  the 
affection  is  confined  to  one  side.  Occasionally  the  mass  may 
give  rise  to  a  severe  neuralgia,  not  confined  to  the  ear  alone, 
but  spreading  over  the  temporal  and  supra-orbital  regions, 
and  sometimes  involving  the  entire   trigeminal  di'=;tribution. 


2-JO  IMPACTED    CERUMEN. 

Sometimes  this  affection  of  the  sensory  nerves  produces  a 
feeling  not  so  much  of  pain  as  of  numbness,  involving  the 
aural  region  or  the  entire  side  of  the  face. 

One  of  the  most  common  reflex  disturbances  is  cough. 
So  common  is  this  that  examination  of  the  ear  is  essential  in 
the  investigation  of  every  case  when  complaint  is  made  of 
this  symptom  alone.  This  cough  is  spasmodic  in  character, 
and  from  its  severity  may  induce  so  much  congestion  of 
the  larynx  as  to  mislead  the  physician  into  believing  that 
the  larvngeal  condition  is  the  cause  rather  than  the  effect  of 
the  symptom. 

Not  only  is  the  auditory  function  perverted  or  impaired, 
but  also  the  mental  condition  of  the  patient  may  be  disturbed. 
The  patient  graduallv  finds  that  he  is  unable  to  concentrate 
his  thoughts  upon  anv  one  ])articular  subject,  and  that  all 
mental  processes  are  slow.  The  condition  may  become  so 
marked  as  entirelv  to  unfit  him  for  any  occupation  requiring 
the  exercise  of  his  mental  faculties.  This  disturbance  is  de- 
pendent entirelv  upon  reflex  action,  and  not  upon  the  impair- 
ment of  the  hearing.  Attention  is  particularly  drawn  to  it 
from  the  fact  that  parents  are  often  inclined  to  consider  chil- 
dren inattentive  when  they  are  really  suffering  from  a  reflex 
disturbance  dependent  upon  some  pathological  process  within 
the  ear.  In  these  cases,  unless  attention  is  particularlv  directed 
to  this  organ  by  an  inij^airment  of  hearing,  serious  errors  are 
liable  to  occur. 

Under  this  same  head  we  must  remember  that  interfer- 
ence with  the  function  of  the  ear  of  the  opposite  side  may 
result  from  the  presence  of  a  foreign  body  within  the  meatus. 
While  this  phenomenon  is  rarely  prominent,  every  one  who 
has  carefully  tested  the  hearing  in  both  ears,  in  cases  where 
the  canal  of  one  side  has  been  occluded  by  a  foreign  body, 
must  have  noticed  that  we  seldom  find  the  ear  on  the  unaf- 
fected side  normal,  although  the  patient  may  be  conscious 
of  no  impairment,  and  if  questioned  will  usuallv  reply  that 
the  other  ear  is  perfectly  sound.  When  we  remember  the  in- 
fluence which  a  sounding  body  held  before  one  car  has  upon 
the  sensitiveness  of  the  organ  of  the  opj^osite  side,  it  is  not 
strange  that  an  occlusion  of  the  external  canal  upon  one  side 
may  seriouslv  intertcre  witii  tlie  hearing  power  of  the  oppo- 
site ear. 

So  far  we  have  considered  simply  reflex  disturbances  of  a 


DIAGNOSIS.  271 

sensory  nature  ;  many  cases  have  been  reported,  however,  in 
which  epileptiform  seizures  have  resulted  from  the  presence 
either  of  impacted  cerumen  or  of  some  other  foreign  body 
within  the  external  auditory  meatus,  the  attacks  being  entirely 
relieved  upon  its  removal.  Dizziness  may  occur  from  the 
lirect  pressure  of  the  impacted  cerumen  upon  the  drum 
membrane,  by  which  the  attached  ossicular  chain  is  crowded 
inward,  increasing  labyrinthine  [tressurc  ;  it  may  result  also 
from  reflex  disturbances  due  to  circulatory  changes  within 
the  semicircular  canals  or  the  intracranial  centres. 

When  the  impaction  takes  {)lace  in  an  ear  which  has  pre- 
viously been  the  seat  of  purulent  inflammation,  in  addition  to 
the  symptoms  already  described,  serious  consequences  may 
result  fnmi  the  obstruction  to  the  free  outflow  of  discharge. 
This  is  particularly  apt  to  occur  in  cases  of  chronic  purulent 
otitis  media  of  long  duration,  where  the  discharge  is  small  in 
(juantity  as  a  rule,  but  may  be  suddenly  increased  in  ann>unt 
from  exposure  to  cold  or  some  other  cause.  In  these  cases, 
the  scant  discharge,  mixed  with  the  normal  cerumen,  dries  in 
the  canal  and  forms  crusts,  sometimes  ui  almost  stony  hard- 
ness, which  prevent  the  exit  of  any  fluid  which  may  be 
formed  within  the  middle  ear  during  an  acute  inflammation 
of  the  parts.  It  is  possible  here  for  the  pent-up  secretion  to 
fuid  entrance  into  the  cranial  cavity,  and  cause  death  by  in- 
volving the  intracranial  structures. 

Diagnosis. —  It  is  impossible  to  make  a  diagnosis  upon 
ratioiKil  sviuptoms  alone,  but  objective  examination  at  once 
reveals  the  condition.  Upon  inspecting  the  parts,  occlusion 
of  the  canal  is  at  once  evident,  and  the  determination  of  the 
exact  nature  of  the  mass  before  removal  is  of  no  importance. 
.\ttention,  however,  should  be  given  to  one  point  in  the  ex- 
amination of  these  cases:  it  is  the  presence  on  the  postero- 
superior  wall  of  the  canal  of  a  mass  consisting  apparently  of 
cerumen,  which  extends  along  this  aspect  of  the  meatus  in- 
ward over  the  drum  membrane,  entirely  or  partially  covering 
it.  This  appearance  is  almost  always  indicative  of  a  pre- 
ceding suppurative  process  within  the  tympanum,  the  foreign 
body  being  really  inspissated  secretion,  mixed  with  a  certain 
amount  of  normal  cerumen.  Before  removing  this,  the  patient 
should  always  be  warned  that  the  ear  may  discharge  after 
the  mass  has  been  removed.  The  subsequent  otorrhoca  does 
not  depend  upon  the  removal  of  the  mass,  but  upon  a  pre- 


272 


IMPACTED    CERUMEN. 


viously  existing  intratympanic  suppuration.  If  not  warned 
beforehand  the  patient  may  scarcely  understand  this.  Where 
the  meatus  is  entirely  occluded,  and  a  view  of  the  deeper 
parts  is  impossible,  this  condition  may  be  present,  and  it  is 

often  wise  for  the  surgeon  to 
protect  himself  even  here,  al- 
though it  is  not  of  as  great  im- 
portance as  when  the  mass  oc- 
cupies the  situation  above  de- 
scribed. 

Prognosis. — The  presence  of 
a  mass  of  cerumen  in  tiie  exter- 
nal auditory  meatus  does  not  of 
itself  constitute  a  menace  to  life, 
nor  does  it  i)revent  a  complete 
restoration  of  the  auditorv  func- 
tion after  the  reuKJval  of  the  for- 
eign body.  The  serious  conse- 
(juences  which  occasionally  fol- 
lt)w  the  presence  of  these  masses 
is  due  to  secondary  pathologi- 
cal changes  which  they  excite, 
either  bv  causing  hvperxmia  and  subsequentlv  inflamma- 
tion, as  the  result  of  their  pressure,  or  by  setting  up  an  in- 
flammatory process  of  desquamative  type  in  the  external 
auditorv  meatus,  with  a  resultant  absorption  of  the  surround- 
ing bonv  walls  or  a  perforation  of  the  membrana  tvmpani. 
When  the  affected  ear  is  the  seat  of  a  chronic  purulent  otitis 
media,  the  presence  of  any  foreign  matter  within  the  canal 
which  mav  prevent  the  free  discharge  of  pus  from  the  middle 
car  renders  the  patient  liable  to  all  the  serious  consequences 
which  mav  follow  pus  retention  in  any  other  part  of  the 
body.  It  seems  curious  that  a  mass  c^f  cerumen  can  offer 
sufficient  resistance  to  pent-up  secretions  to  cause  them  to 
seek  an  exit  through  the  cells  of  the  mastoid  process,  or  to 
discharge  into  the  cranial  cavit}',  rather  than  to  force  their 
wMy  past  the  obstruction  in  the  external  auditorv  meatus. 
The  fact,  however,  remains  that  a  mass  of  cerumen,  lodged  in 
the  meatus  for  a  considerable  time,  will  obstruct  this  passage 
so  completely  that  no  discharge  can  escape.  The  osseous 
walls  of  the  mastoid  cells  vield  more  easilv  to  the  pressure  of 
pent-up  secretions  than  does  this  mass  of  fatt}*  matter.    Again, 


Fig.  89 — Crust  on  supero-posterit)r 
wall,  covering  a  perforation  in 
the  mcmbraiia  tvmpani.  (Natural 
size.) 


I'KOl.NOSIS. 


^71 


in  these  cases  the  mere  presence  of  this  collection  within  the 
meatus  excites  a  certain  amount  of  chronic  inflammation  of 
the  epidermis  lining  the  canal,  this  inflammation  being  usu- 
ally of  the  dcsciuamative  tvpe.  The  slight  amount  of  dis- 
charge from  the  tNinpanic  cavity  mixing  with  these  desqua- 
mated epithelial  cells  forms  a  mass  which  is  exceedingly  fii  in. 
and  which,  increasing  gradually  in  size,  is  capable  of  causing 
absorption  of  the  osseous  walls.  The  extent  to  which  this 
may  progress  is  unlimited,  and  c\tii  the  cranial  cayit\-  may 
be  invaded  and  a  purulent  inlection  of  its  contents  may  re- 
sult. In  cases  where  the  tympanic  membrane  remains  intact, 
the  pressure  of  the  mass  may  force  this  structure  inward 
against  the  bony  tympanic  wall,  and  by  pressure  cause  an 
atrophy  of  the  fibrous  layer  of  the  membrane.  At  the  same 
time  the  desquamative  inflammation  excited  by  the  plug  of 
cerumen  involves  the  superficial  layer  of  the  drum  membrane 
as  well  as  the  canal  walls.  The  epithelial  cells  which  have 
been  cast  off  may  adhere  so  firmly  to  the  atrophic  membrana 
tympani  that  upon  removal  of  the  foreign  body  this  delicate 
septum  may  be  ruptured  in  spite  of  the  greatest  care.  Hven 
if  the  membrane  \s  ruptured.  comj)lete  restoration  of  lunc- 
tion  max  take  place,  although  the  accident  adds  a  certain 
amount  of  gravity  to  the  condition.  It  is  always  well,  there- 
fore, for  the  surgeon  to  |)rotect  himself  by  giving  a  guarded 
prognosis  in  any  case  of  ceruminous  impaction  in  the  canal, 
in  which  the  mass  seems  to  be  of  considerable  firmness,  and 
when  there  is  evidence  that  it  has  existed  for  a  long  time. 
The  effect  upon  the  opposite  ear  should  always  be  borne  in 
mind,  and  a  careful  test  of  the  hearing  power  uj^on  both  sides 
should  be  made  before  and  after  removal.  If  the  accumula- 
tion is  recent,  complete  restoration  of  the  normal  hearing 
power  may  be  confirlently  expected.  If,  however,  we  have 
reason  to  believe  that  the  canal  has  been  obstructed  for  sev- 
eral years,  it  is  probable  that  the  hearing  will  not  be  perfect 
even  after  the  foreign  body  has  been  remf)ved.  Moreover, 
since  complete  occlusion  of  the  meatus  makes  it  impossible 
for  the  observer  to  inspect  the  condition  of  the  deeper  parts, 
an  absolute  opinion  should  be  given  only  after  the  obstruction 
has  been  thoroughly  cleared  awav  and  the  fundus  of  the  canal 
exposed  to  view. 

These  masses  within  the  meatus  exert  considerable  pres- 
sure upon  the  surrounding  walls,  and  their  sudden  removal 
19 


274 


IMPACTED   CERUMEN. 


often  causes  a  transitory  hyperaemia  of  the  parts,  which  par- 
ticularly predisposes  to  the  development  of  a  circumscribed 
inflammation,  and  the  appearance  of  a  furuncle  following 
the  operation  is  by  no  means  of  rare  occurrence.  In  other 
instances,  this  sudden  increase  in  blood  pressure  causes  a 
rupture  of  the  superficial  vessels,  developing  a  blood  bleb 
upon  the  walls  of  the  meatus,  usually  upon  the  inferior  wall, 
close  to  the  membrana.  This  may  attain  such  a  size  as  to 
obstruct  the  canal  considerably,  while  its  color  so  nearly  re- 
sembles that  of  the  ccruminous  deposit  as  to  be  mistaken  for 
it.  The  operator  is  liable  to  inHict  considerable  violence  upon 
the  patient  before  the  mistake  is  discovered,  unless  he  bears 
the  possibilitv  of  this  occurrence  in  mind. 

In  one  instance  coming  under  the  observation  of  the 
author  this  sudden  removal  of  support  to  the  blood  vessels 
was  followed  bv  a  serous  transudation  into  the  tympanum.  The 
amount  of  fluid  etTuscd  was  so  great  as  to  cause  intense  pain 
from  pressure  upon  the  membrana  tympani.  A  free  incision 
through  the  membrana  gave  exit  to  the  tluid,  and  was  fol- 
lowed instantly  by  relief. 

Treatment. — The  first  indication  in  a  case  of  this  char- 
acter is  to  remove  the  mass,  and  it  can  not  be  too  strongly 
insisted  upon  that  when  an  effort  to  remove  such  an  accumu- 
lation from  the  external  auditorv  canal  has  been  instituted,  it 
should  not  be  discontinued  until  the  canal  has  been  completely 
cleared. 

An  exceedingly  pernicious  habit  is  practiced,  not  only  by 
physicians  without  special  training  but  by  many  otologists 
as  well,  of  ordering  these  patients  to  instil  a  few  drops  of  an 
alkaline  solution  into  the  ear  at  regular  intervals  for  the  pur- 
pose of  softening  the  mass  of  cerumen,  to  render  removal 
more  easv  at  a  subsequent  period.  As  we  know  nothing  of 
the  conditions  of  the  deeper  parts,  it  seems  strange  that  this 
method  of  procedure  has  ever  been  countenanced.  The 
symptoms  caused  by  the  obstruction  may  be  so  indefinite 
that  almost  any  condition  mav  coexist,  and  to  allow  the 
patient  to  pass  from  observation  without  determining  defi- 
nitely the  presence  of  any  coexisting  pathological  condition 
within  the  t-vmpanum  is  certainly  unwise.  Another  reason 
for  condemning  this  plan  lies  in  the  fact  that  these  masses 
may  consist  largelv  of  dry  epithelial  cells,  and  the  absorption 
of  moisture  will  considcrablv  increase  their  volume.     In  this 


TRE  ATM  i:  N  T— S  V  R I NG I NG. 


275 


manner  great  pressure  will  be  exerted  upon  the  walls  of  the 
meatus,  causiui^  intense  sutTerinj;  to  the  patient,  and  frequently 
leading  to  a  circumscribed  external  otitis. 

The  cardinal  rule,  therefore,  should  alwavs  be  to  remove 
the  collection  at  the  first  sitting.  The  instrument  which  is 
best  adapted  for  this  purpose  is  the  ordinary  ear  syringe  (Fig. 
82).  In  a  large  majority  of  cases  thoroughly  syringing  the  car 
will  remoye  such  a  collection  in  a  few  moments.  The  solution 
to  be  used  is  a  matter  of  considerable  importance,  for,  as  the 
condition  of  the  deeper  parts  is  unknown,  the  fluid  should  be 
of  such  a  character  thai  its  entrance  into  the  tympanic  cayity, 
through  the  accidental  rupture  of  the  drum  membrane  or 
through  a  preyiously  existing  perforation,  would  be  followed 
by  no  serious  consequences.  The  syringe,  therefore,  must  be 
perfectly  asej)tic,  and  the  solution  used  should  j)Ossess  anti- 
septic properties.  A  solution  of  the  bichloride  of  mercury — 
I  to  5,000  or  I  to  8.000 — is  the  one  which  I  j)refer.  The  fluid 
should  be  used  at  a  lukewarm  temperature,  the  sensations  of 
the  patient  being  the  guide  to  the  exact  temperature  to  be 
employed.  Since  the  removal  of  the  obstruction  in  this  man- 
ner dej>ends  upon  the  passage  of  a  stream  of  water  between 
it  and  the  canal  wall,  and  the  gradual  crowding  outward  of 
the  mass  by  this  current,  the  stream  should  be  directed 
where  the  greatest  space  exists  between  the  foreign  b(j(ly  and 
the  canal  wall.  NaturalU .  it  the  current  imj)inges  directly 
upon  the  centre  of  the  obstruction,  this  will  be  driven  inward 
rather  than  outward.  If,  on  inspection,  we  find  that  the  in- 
spissated secretion  is  firmly  attached  on  all  sides  to  the  walls 
of  the  passage,  it  is  frequently  advisable  to  begin  the  f)rocess 
by  removing  a  small  portion  of  the  mass  close  to  the  canal 
wall  with  a  blunt  curette,  in  order  that  the  stream  may  be 
able  to  p)ass  the  obstruction.  The  force  to  be  used  in  the 
procedure  is  best  guided  bv  the  sensations  of  the  patient ;  the 
syringing  should  never  be  painful,  although  in  certain  in- 
stances the  mere  entrance  of  the  stream  of  water  will  cause 
considerable  dizziness.  It  is  well  to  begin  bv  using  very  little 
force,  gradually  increasing  it  as  may  be  necessary.  If  we 
were  certain  that  the  drum  membrane  were  in  its  normal  con- 
dition it  would  be  almost  impossible  to  rupture  it  by  the  use 
of  the  ordinary  ear  syringe.  As  it  may  be  atrophic,  however, 
care  should  be  taken  that  no  undue  violence  is  employed  in 
our  efforts  at  removal.     Where  inspection  reveals  the  canaJ 


2/6 


IMTACTED    CERUMEN. 


completely  stopped  by  the  mass,  and  the  use  of  the  curette  in 
the  manner  already  described  seems  inadvisable,  the  plan 
usually  followed  is  to  direct  the  syringe  so  that  the  stream  of 
water  will  impinge  first  upon  the  superior  wall  of  the  canal, 
next  the  posterior,  then  the  inferior,  and  last  upon  the  ante- 
rior wall.  If  the  circumference  of  the  canal  is  followed  in  this 
order,  the  instances  will  be  rare  in  which  the  plug  will  not 
be  rapidly  displaced,  the  water  at  some  particular  point  gain- 
ing entrance  between  the  wall  and  the  obstructing  body,  and 
rapidly  forcing  it  outward  with  each  successive  discharge  of 
the  syringe.  We  occasionally  meet  with  cases  which  resist 
all  efiforts  at  removal  in  this  manner ;  in  such  an  event  the 
blunt  curette  must  be  used,  and  the  collection  removed  piece- 
meal. Here  it  should  be  borne  in  mind  that  the  upper  and 
posterior  portion  of  the  drum  membrane  is  nearer  the  opera- 
tor than  the  lower  and  anterior  porti(5n  ;  it  is  unsafe,  there- 
fore, to  undermine  the  deposit  by  following  the  anterior  wall 
of  the  canal  and  then  attempt  its  removal  by  crowding  the 
curette  upward  against  the  remaining  portion,  endeavoring 
to  displace  it  by  traction  outward.  If  the  drum  membrane  is 
sunken,  pressure  will  be  brought  directly  against  this  struc- 
ture and  much  suffering  will  certainly  follow,  and  in  many 
instances  it  will  be  ruptured.     It  is  wiser,  therefore,  to  follow 

the  posterior  wall  of  th- 
canal  inward,  effecting 
removal  of  the  mass  by 
pressing  the  curette  down- 
ward and  forward  toward 
the  anterior  wall,  at  the 
same  time  employing  trac- 
tion outward,  removing 
in  this  way  so  much  of  the 
mass  as  lies  between  the 
curette  and  the  opposite 
canal  wall.  After  the' 
drum  membrane  has  been 
once  brought  into  view, 
the  remaining  fragments 
may  be  displaced  either 
by  the  syringe  or  by  the  use  of  the  curette,  following  any 
particular  manipulation  that  may  seem  adapted  to  the  de- 
mands of  the  individual  case  ;  but  until  this  structure  is  seen, 


Fig.   90. — Method  of  removing  cerumen  with 
the  curette.     (Natural  size.) 


TREATMENT— USE    OF   THE   CURETTE. 

the  plan  above  laid  down  is  the  one  which  should  be  fol- 
iuwed.  Where  the  canal  is  exceedingly  sensitive  we  may 
vary  the  manipulation  by  removing  the  central  portions  of 
the  mass  first,  a  thin  layer  of  cerumen  being  left  on  all  sides 
closely  adherent  to  the  walls ol  the  meatus;  this  tubular  rem- 
nant is  then  broken  down  by  introducing  the  curette  into 
the  channel  thus  prepared,  when,  by  pressing  the  instrument 
toward  the  wall  of  the  meatus,  the  included  fragment  mav  be 
extracted.  If  the  op>erator  should  be  so  unfortunate  as  to 
rupture  the  membrana  tympani,  the  first  care  should  be  thor- 
(jughly  to  cleanse  the  entire  field  by  means  of  an  antiseptic 
solution,  and  thus  reduce  to  a  minimum  the  chances  of  in- 
fection of  the  tympanum. 

A  rather  curious  condiii.ui  .i..i(-.i  was  observed  in  one 
of  my  cases  was  the  sudden  effusion  of  a  large  quantity 
of  serum  into  the  middle  ear  following  the  removal  of  a 
mass  of  impacted  cerumen  which  had  lain  in  the  canal  for 
many  years.  The  only  explanation  that  could  be  offered  in 
this  case  was  that  the  blood  vessels  of  the  tympanum  had 
been    so   c^:  i  by  the  a  the  canal 

that  they  ha  ;eir  tone,      i  rrn??  sub- 

jected them  quite  suddenly  to  the  pressure  of  the  ir- 

rent.  and  resulted  in  a  rapid  transudation  of  the  f\u:  ts 

«^f  the  blood  ;  in  this  case  a  minute  rupture  of  th'_  .ic 

drum  membrane  occurred.  A  few  hours  after  the  operation 
the  patient  was  suffering  intense  pain  :  the  middle  ear  was 
full  of  a  sero-sanguinolent  fluid,  which  passed  out  as  rapidly 
as  possible  into  the  canal  through  the  small  j>crforation  which 
had  been  made.  Feeling  confident  that  no  inflammatory  con- 
dition could  be  present  in  so  short  a  time,  as  strict  antiseptic 
precautions  had  been  taken  throughout  the  entire  procedure, 
the  pain  was  attributed  simply  to  the  pressure  of  the  fluid 
within  the  tvmpanum.  A  long  incision  close  to  the  posterior 
attachment  of  the  membrana  tympani  to  the  tympanic  ring 
evacuated  the  fluid,  the  knife  dividing  the  mucous  membrane 
upon  the  internal  tympanic  wall  at  the  same  time  that  the 
section  of  the  drum  membrane  was  effected.  Relief  *.v2«  im- 
mediate, and  in  thirty-six  hours  the  opening  h.;  m- 
pletelv,  the  patient  regaining  perfect  hearing  a:  t::e 
ten  davs. 

After  a   large  mass  of  cerumen  has  been  removed,  it  is 
well  to  insert  a  pledget  of  cotton  into  the  meatus,  directing 


2/8  IMPACTED    CERUMEN. 

the  patient  to  remove  it  upon  retiring  for  the  night,  after 
which  it  need  not  be  replaced.  Since  these  masses  ordinarily 
contain  a  certain  number  of  parasitic  vegetable  organisms, 
the  patient  should  be  seen  once  or  twice  subsequently  to 
guard  against  the  development  of  these  parasitic  growth: . 
It  is  advisable  during  the  interval  between  the  visits  that  an 
alcoholic  solution  either  of  boracic  acid,  in  the  proportion 
of  forty  drains  to  the  ounce,  or  of  salicylic  acid,  ten  grains  to 
the  ounce,  should  be  instilled  into  the  canal  twice  daily;  this 
will  effectuallv  destroy  any  vegetable  spores  which  may  re- 
main, and  render  a  reaccumulation  less  liable  to  occur.  This 
plan  of  treatment  is  also  indicated,  since,  in  removing  the 
mass,  it  is  not  unusual  that  small  areas  may  be  abraded  and 
render  the  occurrence  of  an  acute  circumscribed  external 
otitis  probable.  No  case  should  be  considered  thoroughly 
cured  until  the  entire  cutaneous  lining  of  the  meatus  is  per- 
fectly normal. 


rii.\rri;!>:   xi\. 

roKKU.N  i5t)i)ii:s  IN    rnK  i,  anai,. 

iEtiology.  W'c  liavf  already  dcscribctl,  under  Impacted 
Cerumen,  the  varicjus  symptoms  which  mav  arise  from  the 
presence  of  any  foreij^n  substance  witliin  the  external  audi- 
tory canal,  but  here  the  presence  of  the  foreign  body  in  the 
canal  is  due  to  natural  causes.  The  symptoms  occasioned  by 
a  foreign  body  in  the  external  auditory  canal,  \yhich  has 
either  developed  there  sjxmtaneously  or  has  obtained  lodg- 
ment there  by  accident  or  design,  are  exactly  similar.  We 
shall  therefore  omit  a  repctitit)n  of  the  symi>tomatology,  and 
confme  ourselves  to  the  consideration  of  the  nature  of  the 
substances  which  are  met  with  in  this  locality,  and  the  meas- 
ures which  may  be  necessary  to  effect  their  removal. 

Pathology. — These  foreign  substances  may  be  divided 
into  two  great  classes:  the  inorganic  and  organic.  The  inor- 
ganic substances  which  have  been  removed  from  the  external 
meatus  are  almost  infinite  in  number.  Children  seem  t(j  take 
special  delight  in  introducing  into  the  meatus  any  article 
which  can  be  made  to  enter  it.  Thus  we  trecjuently  find 
buttons,  glass  beads,  pebbles,  sand,  broken  glass — in  fact, 
anything  which  chance  ma\  throw  in  tluir  wa\ — introduced 
into  this  passage.  A  pernicious  habit,  frecjuently  ad()j)ted, 
is  the  introduction  of  cotton  into  the  ears  of  a  child  when 
it  is  taken  out  of  doors  on  a  cold  day  ;  the  mother  often 
neglects  to  remove  this,  and  the  child  may  subsecpiently 
crowd  it  deeply  into  the  meatus  in  its  efforts  to  disKjdge  it. 
In  this  situation  it  may  remain,  often  for  many  years,  and  it  is 
not  uncommon  in  dispensary  practice  to  find  a  small  plug  of 
cotton  forming  the  nucleus  of  a  mass  of  impacted  cerumen, 
the  patient  being  unable  to  state  when  the  foreign  substance 
was  introduced. 

Among  the  organic  substances  found  are  apple  seeds, 
watermelon  seeds,  cherry  pits,  the  shells  of  edible  nuts,  small 


28o  FOREIGN    BODIES    IN    THE    CANAL. 

pieces  of  straw  which  have  been  used  by  the  patient  to 
scratch  the  ear,  or  minute  splinters  of  wood  which  may  have 
been  broken  off  in  the  canal  during  a  similar  effort  on  the 
part  of  the  patient.  Occasionally  the  body  of  a  dead  insect 
is  found,  the  insect  having  gained  entrance  to  the  meatus 
accidentally,  and,  being  unable  to  escape,  has  remained  there 
until  removed  by  artificial  measures.  A  living  insect  usually 
causes  such  marked  symptoms  by  its  presence  in  the  canal 
that  immediate  efforts  are  instituted  for  its  removal.  When 
leeches  are  carelessly  applied  to  the  region  of  the  ear — the 
meatus  being  allowed  to  remain  open  during  the  operation — 
the  animal  may  detach  itself  from  the  point  of  application, 
and,  making  its  way  into  the  meatus,  may  attach  itself  to  the 
drum  membrane  and  cause  intense  suffering.  Sometimes  the 
eggs  of  the  common  house-fly  ^re  deposited  in  the  canal  and 
subsequently  become  developed  into  living  insects,  constitu- 
ting a  condition  distressing  to  the  patient  and  disgusting  to 
the  observer. 

Symptomatology. — Very  little  need  be  said  about  the 
symptoms  produced  by  a  foreign  body,  as  we  have  already 
discussed  the  subject  thoroughly  under  Impacted  Cerumen. 

That  a  foreign  substance  may  lie  in  the  meatus  for  a  num- 
ber of  years  without  giving  rise  to  any  symptoms,  and  then 
suddenly  make  its  presence  felt  by  manifestations  of  unusual 
severity  at  first,  appears  strange  ;  yet  this  is  easily  under- 
stood, if  we  consider  that  an  irregularly  shaped  body  may, 
in  this  locality,  exert  no  pressure  on  the  surrounding  walls, 
but  if  suddenly  displaced  ever  so  little  may  impinge  upon 
delicate  and  sensitive  parts.  Any  foreign  substance  which 
increases  in  volume  by  the  absorption  of  moisture  is  particu- 
larly liable  to  produce  symptoms  of  increasing  severity. 
Beans  or  seeds  which  when  dry  may  be  easily  dropped  into 
the  canal  become  moistened  by  perspiration,  and  attain  such 
a  size  that  their  spontaneous  exit  becomes  impossible.  While 
this  increase  in  volume  may  not  be  sufficient  to  constitute  a 
source  of  discomfort,  the  introduction  of  water  into  the 
meatus  while  bathing  may  bring  about  this  result.  Again, 
if  there  is  at  the  same  time  a  suppurative  otitis  media,  the 
discharge  from  the  tympanum  will  cause  a  foreign  body  to 
increase  in  volume.  The  local  irritation  which  a  foreign 
body  exerts  upon  the  walls  of  the  canal  increases  the  secre- 
tion from  the  cutaneous  lining,  the  superficial  epithelium  is 


DIAGNOSIS— rROGNUSIS.  28  I 

thrown  off  rapidly,  and  the  canal  is  hlled  with  these  white, 
moist  scales.  This  condition  is  particularly  favorable  for  the 
development  of  the  various  forms  of  parasitic  growths,  or  of 
a  local  infectious  process  ending  in  a  circumscribed  or  diffuse 
inflammation  of  the  walls.  Naturally  all  of  these  manifesta- 
tions are  more  common  among  the  classes  who  pav  little 
attention  to  personal  cleanliness,  or  are  exposed  to  surround- 
ings which  render  local  infection  especially  easy. 

When  the  middle  ear  is  the  seat  of  suppuration,  the  for- 
eign bodv  may  interfere  with  projH'r  drainage,  and  then 
symptoms  of  pus  retention  ensue. 

Diagnosis.  —  The  recogniti(jn  of  anv  foreign  substance 
lying  within  a  perfectly  patulous  canal  is  exceedingly  sim- 
ple. Unfortunately,  however,  these  i)atients  arc  seldom  seen 
immediately  after  the  introduction  of  the  foreign  body  and 
before  efforts  have  been  made  to  effect  its  removal.  These 
attempts  at  the  hands  of  the  patient  are  necessarily  unskillful, 
and  result  in  the  intlicticjn  of  considerable  injury  to  the  sur- 
rounding parts,  if  the  case  is  inspected  at  the  end  of  a  few 
days,  the  canal  may  be  so  swollen  that  the  deeper  parts  are 
entirely  invisible,  the  softer  tissues  prolapsing  about  the  for- 
eign body  and  completely  hiding  it  ;  while  at  the  same  time 
the  secretion  from  the  parts,  the  desciuamated  e{)ithelium, 
and  the  presence  of  dried  blood  which  has  followed  the  efforts 
at  removal,  so  distort  the  normal  appearance  that  an  exact 
diagnosis  is  a  matter  of  great  difficulty.  The  parts  may  be 
so  tender  that  only  the  smallest  si)eculum  can  be  introduced, 
while  manipulation  may  be  impossible.  .  Under  these  condi- 
tions, our  diagnosis  must  depend  entirely  uj)on  the  history  ; 
when  this  clearly  indicates  the  nature  of  the  affection  with 
which  we  have  to  deal,  it  is  unwise  to  jtrolong  the  examina- 
tion, as  the  indications  for  treatment  are  identical,  no  mafUr 
what  the  nature  of  the  substance  may  be. 

Prognosis. — The  outcome  of  the  condition  will  depend 
more  upon  the  local  disturbance  which  is  ])resent  than  upon 
the  nature  of  the  foreign  body  or  its  location.  The  parts  in 
some  cases  are  exceedingly  tolerant,  while  in  others  compara- 
tively harmless  substances  may  give  rise  to  severe  symptoms. 
Probably  nothing  increases  the  gravity  of  a  case  to  such  an 
extent  as  unsuccessful  attempts  at  removal,  the  body  itself 
doing  less  harm  than  unskillful  efforts  in  this  direction. 

When  the  condition  has  existed  for  a  considerable  period. 


282  FOREIGN    BODIES    IN    THE    CANAL. 

the  presence  of  profuse  purulent  discharge  will  indicate  that 
the  tympanum  has  been  invaded,  while  involvement  of  the 
mastoid  cells  or  interference  with  the  outflow  of  pus  will  be 
evidenced  bv  characteristic  signs. 

Treatment. — The  instrument  which  should  be  employed 
for  the  relief  of  this  condition  is  the  ear  syringe.  It  is  prob- 
ably safe  to  say  that  our  first  efforts  should  always  be  to  clear 
the  canal,  if  possible,  by  this  means  alone.  Although  it  may 
seem  perfectly  simple  to  remove  the  foreign  body  with  the 
forceps,  with  hooks,  or  similar  instruments,  attempts  to  grasp 
hard,  smooth  objects  usually  result  in  crowding  them  deeper 
into  the  canal,  where  thev  become  impacted  and  are  removed 
with  great  difficulty.  A  stream  of  water  thrown  with  con- 
siderable force  into  the  meatus  is  usually  sufficient  to  dislodge 
any  obstruction,  while  it  inflicts  no  violence  upon  the  parts. 
The  only  instance  in  which  it  may  be  wise  to  attempt  re- 
moval by  manipulation  is  in  the  case  of  seeds  or  dried  vege- 
table substances,  which  may  increase  in  volume  so  rapidly 
when  moistened  as  to  fill  the  canal  completely.  If  a  sharp 
hook  can  be  made  to  penetrate  such  a  foreign  body  to  a  con- 
siderable depth,  this  is  usually  the  simplest  measure  for  its 
removal.  Forceps  should  only  be  used  where  the  body  is 
thin  and  flat,  and  may  be  grasped  easily  in  the  jaws.  When 
the  contour  of  the  body  is  more  or  less  spherical,  the  efforts 
to  grasp  it  will  usually  result  in  the  instrument  slipping  and 
actually  crowding  the  obstruction  toward  the  fundus  of  the 
canal.  Continued  efforts  in  this  direction  mav  often  force  the 
object  against  the  tympanic  membrane,  and  even  into  the  mid- 
dle ear.  It  is  sometimes  possible  to  introduce  a  blunt  curette 
between  the  object  and  the  canal  wall  until  the  instrument 
has  passed  the  obstruction  ;  the  instrument  is  then  withdrawn, 
and  the  foreign  body  removed  with  it.  It  mav  be  necessary, 
in  the  case  (3f  small,  soft  objects,  to  disintegrate  them  in  the 
canal  by  instruments,  and  remove  thcni  piecemeal.  This  is 
particularly  true  of  seeds,  the  shell  being  broken,  and  the 
soft  interior  removed  by  the  curette,  after  which  the  remain- 
der of  the  shell  can  be  easily  taken  away. 

The  necessity  of  auccsthesia  must  be  determined  in  each 
individual  case.  It  is  an  error,  however,  to  prolong  the 
efforts  at  removal  where  the  patient  is  extremely  nervous,  on 
account  of  the  damage  which  may  be  done  to  the  surround- 
ing parts ;    and,  unless  they  meet  with  prompt  success,  the 


TREATMENT— EXTERNAL    OPERATION.  283 

patient  should  be  thorout^hly  ancesthetized  before  continuing 
the  operation.  In  some  rare  instances,  where  the  condition 
has  been  neglected,  the  meatus  may  become  so  small  that  it 
is  impossible  to  extract  the  foreign  body  through  the  natural 
passage.  Under  these  circumstances  a  more  radical  jiroce- 
dure  becomes  necessary. 

The  patient  being  thoroughly  anjusthctizcd.  the  parts 
above  and  behind  the  ear  are  shaved,  thoroughly  scrubbed 
with  soap  and  water,  washed  with  a  hvc-pcr-cent  carbolic 
solution  and  subseciuentlv  with  ether,  the  external  meatus 
having  been  previcnislv  syringed  with  a  two-pcr-ccnt  carbolic 
solution  or  some  other  antiseptic  fluid,  and  tamponed  with 
iodoforin  gauze.  An  incision  is  then  made  from  just  below 
the  insertion  of  the  lobule,  upward  along  the  line  of  attach- 
ment of  the  auricle  to  a  point  just  above  the  meatus,  and  then 
forward  as  far  as  the  helix  ;  the  fibro-cArtilaginous  canal*  is 
then  loosened  fn^m  its  attachment  bv  means  of  the  periosteum 
elevator,  the  instrumetit  being  ap|)lied  first  below  and  then 
behind,  the  superior  wall  being  detached  last,  in  the  same 
way  the  {periosteum  of  the  canal  is  sej)arated  from  the  bone, 
and  the  fibro-cartilaginous  tube  is  divided  transverselv  as  near 
the  drum  membrane  as  possible. 

This  anterior  flaj).  consisting  of  the  auricle  and  iiit-  s<»it 
parts  of  the  meatus,  is  turned  forward,  and  entrance  is  thus 
gained  to  the  bonv  meatus  directly,  and  the  path  to  the  tor- 
eign  body  is  shortt-ncd  bv  the  length  of  the  cartilaginous  canal. 
This  amount  of  gain  is  inconsiderable  when  we  remember  that 
the  parts  are  covered  with  bhiod,  and  the  view  to  a  degree  ob- 
structed bv  the  hemorrhage.  If  the  fibrous  canal  is  swollen, 
as  the  result  of  secondary  inllammation.  and  this  is  the  only 
obstacle  to  the  removal  of  the  foreign  body,  we  may  be  able 
to  extract  it  at  once  after  the  flap  has  been  turned  forward. 
In  case  the  object  is  found  so  firmly  fixed  in  the  canal  that 
efforts  at  extraction  are  still  futile,  the  lumen  of  the  meatus 
can  be  enlarged  with  a  chisel  by  carefully  chipping  away 
the  bone  from  the  posterior  wall  until  sufficient  space  is  ob- 
tained to  remove  the  object.  It  is  better  to  enlarge  the  pas- 
sage by  the  removal  of  a  portion  of  the  osseous  wall  than 
to  attempt  to  extract  the  body  by  forcible  manipulation.  The 
operation  presents  no  difficulties,  and  we  should  never  delay 
in  adopting  this  plan  whenever  extraction  through  the  natural 
passage  seems  impossible.     If,   in   (^ur  efforts,   the  tympanic 


284  FOREIGN    BODIES    IN    THE    CANAL. 

cavity  has  been  unavoidably  opened,  this  feature  does  not 
add  to  the  gravity  of  the  condition.  The  parts  should  be 
thoroughly  cleansed,  and  the  wound  in  the  tympanic  mem- 
brane will  soon  close,  and,  as  a  rule,  the  middle  ear  suffers 
very  little  from  the  accident.  After  the  purpose  for  which  the 
operation  has  been  undertaken  iS  accomplished,  the  soft  parts 
should  be  replaced,  and  the  line  of  incision  sutured  by  a  con- 
tinuous subcutaneous  catgut  suture ;  a  rubber  tube  should 
be  inserted  into  the  meatus,  both  for  the  purpose  of  drainage 
and  to  keep  the  parts  in  position.  Sufficient  drainage  is  se- 
cured in  this  way,  and  primary  union  throughout  the  entire 
length  of  the  incision  should  be  looked  for.  If  there  is  but 
little  inflammatory  change  in  the  tissues  of  the  meatus  as  the 
result  of  the  presence  of  the  foreign  body,  a  light  tampon  of 
iodoform  gauze  may  be  inserted  instead  of  the  drainage  tube. 
This  should  extend  to  the  fundus  of  the  meatus  to  secure 
proper  drainage,  and  will  be  found  to  support  the  walls  of 
the  canal  sufficiently.  Unless  the  temperature  indicates  the 
necessity  for  doing  otherwise,  the  dressing  may  remain  un- 
touched for  six  days,  when  the  parts  will  have  united  com- 
pletely. If  there  has  been  much  previous  laceration  of  the 
soft  parts,  it  is  usually  wise  to  change  the  dressing  at  the  end 
of  the  second  or  third  day.  If  much  discharge  is  found  at 
this  time  the  canal  should  be  irrigated  ;  but  if  the  parts  are 
dry  this  is  not  necessary.  The  tube  may  be  removed  at  the 
first  dressing  and  the  tampon  of  gauze  substituted.  The  only 
unpleasant  sequel  which  can  result  from  the  operation  is  the 
possible  narrowing  of  the  canal  from  cicatricial  contraction, 
and  this  can  be  avoided  if  the  parts  are  properly  apposed 
after  the  operation  and  held  in  position  for  twenty-four  or 
forty-eight  hours. 


CHAPTER  XV. 

EXOSTOSES  OF  THE  EXTERNAL  AUDITORY  MEATUS. 

^Etiology. — The  development  of  a  new  growth  of  an  osse- 
ous character  in  the  external  canal  has  been  attributed  to 
various  causes.  It  was  formerly  supposed  that  a  gouty  or 
rheumatic  diathesis  predisposed  to  the  condition,  although 
statistics  fail  to  bear  out  this  view;  and  the  same  may  be  said 
of  specific  disease. 

Persistent  irritation  of  the  external  auditory  canal,  espe- 
cially bv  the  presence  of  a  purulent  secretion  such  as  occurs 
in  individuals  suffering  from  neglected  purulent  otitis  media, 
seems  to  be  the  most  common  certain  cause  for  the  develop- 
ment of  these  bony  growths.  Race  also  exerts  a  decided 
influence,  the  growths  being  more  commonly  met  with  among 
Europeans  than  among  the  inhabitants  of  our  country,  al- 
though among  the  aborigines  the}'  were  of  frequent  occur- 
rence, as  is  proved  bv  an  examination  of  skulls  discovered 
through  archasological  research.  The  natives  of  the  Ha- 
waiian Islands  also  manifest  the  condition  quite  commonly, 
and  from  their  aquatic  habits  this  fact  lends  great  weight  to 
the  argument  that  the  irritating  action  of  salt  water  exerts  a 
most  important  influence  in  the  formati(^n  of  these  osseous 
growths. 

Their  occasional  occurrence  in  successive  generations  in 
the  same  family  seems  to  point  to  a  certain  hereditary  predis- 
position, although  this  is  far  from  proved. 

Pathology. — The  portion  of  the  canal  in  which  these 
growths  are  most  frequentlv  found  is  either  the  junction  of 
the  cartilaginous  and  bony  meatus  or  the  deeper  portion  of 
the  osseous  channel.  They  occur  in  two  forms,  either  as  dis- 
tinct pedunculated  masses,  or  as  protuberances  from  the  bony 
wall  arising  by  a  broad  base.  In  structure  they  may  be  either 
cancellous  or  hard  as  ivory.  A  single  bony  mass  may  be 
present,  or,  as  more  frequently  happens,  they  are  multiple, 
projecting  into  the  lumen  of  the  canal  from  various  aspects. 

(285) 


286     EXOSTOSES    OF    THE    EXTERNAL    AIDITORY    MEATUS. 

Where  the  canal  is  obstructed  by  multiple  growths,  it 
preserves  its  circular  form  in  a  modified  degree,  the  space 
left  between  the  obstructing  masses  lying  in  the  axis  of  the 
meatus.  Where  a  single  excrescence  of  large  size  is  the  cause 
of  occlusion,  the  meatus  is  converted  into  a  slitlike  passage 
by  the  approximation  of  the  growth  to  the  opposite  wall. 

Symptomatology. — A  small  bony  tumor  in  the  external 
canal  gives  rise  to  no  subjective  evidence  of  its  presence,  and 
even  where  the  deposit  is  multiple  the  condition  may  be  dis- 
covered only  by  accident.  When  they  attain  a  sufficient  size 
to  obstruct  the  passage  to  a  considerable  degree,  the  func- 
tion of  audition  is  interfered  with.  Certain  other  subjec- 
tive symptoms  now  make  their  appearance  :  the  ear  feels 
full  and  stopped  up,  there  is  autophonia,  and  quite  commonly 
subjective  noises.  The  normal  secretion  from  the  walls  of 
the  meatus  may  collect  beyond  the  tumor,  and,  being  unable 
to  find  exit  on  account  of  its  presence,  becomes  impacted, 
and  exerts  a  steadily  increasing  pressure  upon  the  membrana 
tympani  and  the  walls  of  the  bony  meatus.  This  pressure 
tends  to  increase  the  condition  from  the  mechanical  irritation 
which  it  causes.  If  the  accumulation  is  not  removed  arti- 
ficiallv,  the  pressure  may  excite  an  acute  inflammation  within 
the  middle  ear,  or  an  acute  external  otitis.  This  is  especiallv 
prone  to  occur  if  water  is  introduced  into  the  meatus,  causing 
the  mass  to  suddenly  increase  in  volume.  On  the  other  hand, 
an  acute  inflammation  of  the  middle  ear,  arising  from  another 
cause,  may  lead  to  serious  results  on  account  of  the  obstruc- 
tion to  the  exit  of  the  fluid  products  of  the  inflammation.  For 
this  last  reason  exostoses  of  large  size  become  a  menace  to 
lite,  and  when  once  discovered  the  patient  should  be  cau- 
tioned to  submit  to  an  examination  periodicallv  at  the  hands 
of  an  expert,  in  order  that  no  extensive  accumulation  of  ceru- 
men shall  take  i)lace  bevond  the  obstruction  and  cause  com- 
plete occlusion. 

The  degree  to  which  these  masses  interfere  with  hearing 
varies  considerably.  Even  when  the  meatus  is  excecdinglv 
narrow  the  power  of  audition  mav  not  be  noticeably  impaired 
in  the  ordinarv  intercourse  of  life. 

Diagnosis. — Otoscopic  examination  usually  renders  the 
diagnosis  clear  at  once.  Where  the  growth  is  pedunculated, 
bulging,  and  broad,  and  especially  if  the  surface  is  covered 
by  a  thin  laver  of  cerumen,  the  examiner  may  at  first  be  mis- 


DIAGNOSIS— PROGNOSIS. 


2S7 


led  as  to  the  character  of  the  obstruction,  the  appearance  pre- 
sented in  these  cases  being  quite  similar  to  epithelial  debris 
mixed  with  cerumen  closely  applied  to  the  wall  of  the  meatus. 
Manipulation  by  means  of  the  curette  at  once  reveals  the  true 
character  of  the  formation.  Upon  removal  of  the  layer  of 
dried  secretion  upon  the  surface  by  means  of  the  curette,  the 
integument  is  frequently  found  to  be  eroded  and  exccssivch- 
tender  to  the  touch,  rndoubtedly  the  efforts  of  the  patient 
to  remove  these  crusts  when  the  growth  is  near  the  orifice  of 
the  canal  acc(^unts  for  the  steady  growth  in  manv  instances. 
Located  close  to  the  drum  membrane,  ami  presenting  as  one 
or  more  small  rounded  protuberances,  these  bony  excrescences 
may  resemble  closely  a  localized  bulging  in  Shrajjucl's  mem- 
brane, but  here  again  the  probe  reveals  the  true  condition. 

The  clinical  historv,  and  the  resistance  offered  to  tiic  im- 
pact of  the  jtrobe,  discloses  the  true  nature  of  the  mass.  The 
same  points  distinguish  it  from  a  circumscribed  external  otitis, 
or,  wiierc  the  neoplasm  arises  from  a  broad  base,  from  a  symp- 
tomatic iliffusc  otitis  externa. 

Prognosis. —  These  neoplasms  follow  a  different  course  in 
different  cases.  The  progress  followed  by  any  individual 
growth  is  probably  more  dcjtendent  uj)on  the  causes  opera- 
tive in  its  production  than  uj>on  any  other  condition.  Thus, 
if  it  is  secondary  to  a  [)uruk-nt  inllammation  of  the  middle 
ear,  the  mass  will  undoubtedly  increase  in  size  until  the  irri- 
tating discharge  has  been  controlled.  Those  cases  depending 
upon  diathetic  conditions  alone  undoubtedly  advance  less  rap- 
idly, and  here  the  increase  in  size  is  seldom  sufficient  to  de- 
mand operative  treatment  unless  an  intercurrent  acute  inflam- 
mation of  the  tympanum  takes  place,  necessitating  the  removal 
of  the  exostosis  to  secure  {)roper  drainage.  After  removal 
the  growth  does  not  tend  to  reappear.  We  are  seldom  able 
to  restore,  however,  the  normal  lumen  of  the  meatus,  even 
though  the  tumor  is  completely  taken  awav.  The  local  irri- 
tation which  must  nccessarilv  follow  the  operation  excites  a 
certain  amount  of  inflammation  in  the  bony  tissue  which  leads 
to  hypertrophy  of  the  wall  of  the  bony  canal,  anri  consequent 
narrowing  of  its  lumen. 

The  possibility  of  an  exostosis  degenerating  into  a  malig- 
nant neoplasm  should  be  borne  in  mind,  especially  when  it  is 
situated  near  the  orifice  of  the  meatus  and  constitutes  a  source 
of  local  discomfort.     Under  these  condition^  thf  j>,itifnt  con- 


288     EXOSTOSES   OF   THE   EXTERNAL    AUDITORY    MEATUS. 

tinually  irritates  the  canal  in  this  region  by  the  introduction 
of  the  finger  or  some  blunt  instrument  to  relieve  the  pruritus 
— a  process  which  serves  to  keep  the  integument  over  the 
bony  growth  denuded  of  its  superficial  epithelium.  From 
this  constant  local' irritation  a  benign  osseous  tumor  may  as- 
sume the  form  of  an  osteo-sarcoma.  These  remarks  would 
scarcely  apply  to  growths  located  in  the  deep  canal. 

Regarding  the  function  of  the  organ,  the  remarks  already 
made  concerning  the  increase  in  the  size  of  the  tumor  may 
be  taken  as  an  index  of  its  probable  effect  in  this  direction. 
Lesions  of  this  character  endanger  life  only  when  they  act  as 
an  obstruction  to  free  drainage  from  the  more  deeply  situated 
partswhcn  these  are  the  seat  of  an  inflammatory  process. 

Treatment. — Where  the  exostosis  is  deeply  located,  of 
small  size,  and  gives  rise  to  no  symptoms,  operative  treatment 
is  unwarrantable.  It  is  well,  however,  to  keep  the  patient 
under  observation,  the  ear  being  examined  at  long  intervals 
to  ascertain  whether  the  growth  is  progressive  or  has  ceased 
to  increase  in  size.  It  is  surprising  how  narrow  the  meatus 
may  become  and  yet  impair  in  no  degree  the  function  of 
audition. 

When  multiple  growths  are  present,  if  the  hearing  is  not 
noticeably  impaired,  interference  is  scarcely  called  for,  al- 
though the  patient  should  be  advised  to  submit  to  an  occa- 
sional examination  in  order  that  any  secretion  which  may 
have  collected  mav  be  removed  before  it  has  become  im- 
pacted so  firmly  as  to  prevent  its  dislodgment  without  great 
difficulty.  Sea  bathing  should  be  interdicted,  on  account  of 
the  irritating  effect  of  the  salt  water,  and  at  the  same  time  the 
patient  should  be  cautioned  against  allowing  fluid  of  anv  sort 
to  enter  the  meatus,  since  by  this  means  any  collection  of 
cerumen  or  of  desquamated  epithelial  cells  may  become  so 
augmented  in  volume  as  to  excite  severe  pressure  symptoms. 

Where  the  obstruction  of  the  meatus  is  almost  complete, 
so  as  to  interfere  with  the  function  of  audition,  or  where  the 
slightest  increase  in  size  would  entirely  close  the  canal,  it  is 
our  duty  to  remove  the  exostosis.  The  precise  manner  in 
which  this  is  to  be  done  will  vary  according  to  its  location, 
its  form,  and  the  individual  preference  of  the  operator. 
When  the  growth  springs  from  a  narrow  base,  and  is  situ- 
ated near  the  entrance  of  the  bony  canal,  it  is  usually  an 
easy   matter  to   separate   it  by  a  chisel   introduced   into  the 


TREATMENT. 


289 


meatus,  and  if  carefully  conducted  the  procedure  does  not 
endang-er  the  parts  within  the  tympanum.  When  more  than 
one  growth  is  present,  or  when  the  c<jndition  occurs  close 
to  the  drum  membrane,  or  springs  from  an  extensive  attach- 
ment, this  simple  measure  is  not  efficacious,  as  we  have  no 
means  of  protecting  the  deeper  structures.  Moreover,  those 
growths,  springing  from  a  broad  base,  are  usuallv  of  an 
ivorylike  hardness,  and  are  but  little  affected  by  chisels 
small  enough  to  be  introduced  into  the  canal,  the  instrument 
frequently  glancing  from  the  surface  of  the  tumor  and  inflict- 
ing serious  injury  upon  the  parts  beyond.  The  surgical  en- 
gine may  be  used  in  these  cases,  the  base  of  the  growth  being 
perforated  bv  means  of  fine  drills,  thus  weakening  its  attach- 
ment to  the  wall  of  the  meatus  and  permitting  its  removal 
with  cutting  instruments,  or  the  entire  obstruction  mav  be 
cut  awav  with  a  jiroperlv  constructed  bun".  Where  one  is 
familiar  with  the  manijailation  of  the  deiit;il  engine,  the  oper- 
ation, if  carried  out  in  this  manner,  can  be  performed  with 
greater  safetv  than  by  anv  (ilher  method. 

Where  the  growth  is  so  large  as  to  render  it  im|)Ossible  to 
discover  the  exact  site  of  its  attachment  it  is  well  to  expose 
the  orifice  of  the  bonv  canal  bv  an  incision  behind  the  auricle, 
and  to  displace  the  auricle  forward  so  as  to  gain  better  access 
to  the  bonv  meatus.  The  operative  technicjue  is  the  same  as 
that  already  detailed  for  the  removal  of  foreign  bodies.  After 
this  has  been  done,  either  the  chisel,  the  drill,  or  the  burr  may 
be  used,  according  to  the  preference  of  the  operator. 

Where  the  growth  is  located  upon  the  j)osterior  wall  it 
should  be  remembered  that,  although  the  tumor  mav  be 
eburnated,  the  tissue  of  the  mastoid  itself  is  comiiaratively 
soft,  and  if  the  chisel  is  employed  to  remove  the  growth  it  is 
much  simj)lcr  to  remove  a  thin  lamella  from  the  mastoid,  to- 
gether with  the  tumor,  than  to  attempt  to  chisel  through  the 
base  of  the  growth.  Less  traumatism  is  inflicted  upon  the 
surrounding  j)arts  bv  this  procerlure,  and  the  ultimate  result 
is  correspondinglv  more  satisfactory. 

Where  a  purulent  otitis  media  of  long  duration  is  present, 
exostoses  of  moderate  size  should  be  removed  on  account  of 
the  probability  of  a  steady  growth  with  the  consequent  ob- 
struction to  free  drainage.  In  such  cases  it  would  be  much 
better   to    detach    the    auricle    than    to    attempt    to    operate 

through  the  canal.     If  this  is  done,  we  may  at  the  same  time 
20 


290     EXOSTOSES    OF    THE    EXTERNAL    AUDITORY    MEATUS. 

remove  all  carious  bone  from  the  tympanum,  and  effect  a  cure 
of  the  purulent  otitis. 

Concerning  internal  medication  but  little  can  be  said. 
Anti-rheumatic  remedies  exert  practically  no  influence  upon 
the  progress  of  the  local  condition,  and  it  is  only  where  a  dis- 
tinct specific  history  can  be  elicited  that  we  have  any  reason 
to  hope  for  improvement  following  the  administration  of  in- 
ternal remedies.  If  the  osseous  mass  within  the  meatus  is 
considered  to  be  of  syphilitic  origin,  the  administration  of 
large  doses  of  iodide  of  potassium  should  be  tried  before  re- 
sorting to  operative  procedures.  Even  in  these  most  favor- 
able cases  the  results  are  often  disappointing. 


CHAI'THR    XVI. 

WOUNDS    AND    INirKIKS    OK    THK    MKNIItKANA    TV.MrANI. 

iCtiolog^. — The  partition  separating  the  middle  ear  from 
the  external  portion  of  the  conducting  mechanism  mav  suffer 
injury  either  bv  direct  violence  from  instruments  introduced 
into  the  meatus,  or  its  continuity  may  be  destroyed  by  indi- 
rect violence,  by  the  sudden  condensation  of  the  air  \yithin 
the  meatus,  as  when  a  heavv  gun  is  fired  close  to  the  ear. 
or  when  one  is  in  the  vicinity  of  a  heavy  explosion.  From 
the  anatomical  structure  of  the  drum  membrane,  we  remem- 
ber that  its  su{)erior  portion  is  directly  continuous  with  the 
integument  of  the  superior  wall  of  the  meatus.  Traction 
upon  the  auricle,  therefore.  esj»ecially  in  children,  may  pro- 
duce a  rent  in  this  [>()rti(jn  of  the  membrana.  Irritating  sub- 
stances introduced  into  the  canal  for  the  relief  of  pain  in 
the  ear,  or  for  tor)thaclie.  may  produce  a  superficial  inflam- 
mation of  the  lining  membrane  of  the  canal  and  oi  the  drum 
membrane:  in  the  same  maimer  a  vegetable  parasite  grow- 
ing within  the  meatus  causes  a  diffuse  external  otitis.  When 
moderate  in  degree,  such  an  inflammation  amounts  to  nothing 
more  than  a  dermatitis,  the  superficial  epithelium  being  exfo- 
liated and  the  deeper  layers  exj)Osed.  When  the  inflamma- 
tion is  of  greater  intensity  actual  tissue  necrosis  takes  j)lace. 
and  the  drum  membrane  may  be  perforated,  thus  exposing 
the  tympanic  cavity  not  only  to  infection  from  the  air,  but 
also  to  the  direct  action  of  the  substance  which  has  excited 
the  inflammation  within  the  canal  and  has  caused  the  perfora- 
tion in  the  membrana  tympani.  As  a  result  of  this  we  have 
inflammation  of  the  middle  ear  grafted  upon  the  already  ex- 
isting inflammation  of  the  external  meatus.  Perforation  of 
the  membrane  from  inflammation  within  the  tympanic  cavity 
is  of  secondary  importance  to  the  original  disease,  and  pre- 
sents no  characteristic  features. 

Pathology. — From    the   introduction   of   instruments  into 

the  canal  injury  to  the  membrana  tym])ani  is  usually  effected 

(291) 


292     WOUNDS  AND  INJURIKS  OP^  THE   MEMBRANA  TYMPANI. 

in  the  upper  and  posterior  quadrant,  since  this  region  is  most 
accessible,  the  angle  formed  between  the  cartilaginous  and 
bony  canal  protecting  the  anterior  portion  of  the  membrane 
from  injury.  When  the  rupture  follows  a  sudden  condensa- 
tion of  air  in  the  meatus,  either  from  a  blow  upon  the  ear 
or  from  an  explosion,  the  rent  is  most  frequently  situated  in 
the  postero-superior  quadrant,  from  the  fact  that  the  greatest 
breadth  of  the  tympanic  cavity  lies  in  this  region.  Owing  to 
some  irregularity  in  the  position  of  the  structure  an  accident 
of  this  character  may  produce  a  rupture  in  the  anterior  por- 
tion  of  the  membrane.  Following  traction  upon  the  auricle 
the  upper  part  is  most  frequently  torn,  and  here  the  rupture 
is  usually  confined  to  the  region  of  Shrapnell's  membrane,  the 
membrana  vibrans  being  to  an  extent  protected  by  its  loose 
attachment  to  the  membrana  flaccida.  Openings  into  the  tym- 
panic cavity  are  usually  single  when  of  traumatic  origin,  but 
occasionally  multiple  perforations  are  found.  They  vary  in 
shape  from  a  simple  rent,  the  edges  of  which  are  only  slightly 
separated,  to  an  irregularly  circular  opening,  as  occurs  when 
the  force  is  considerable,  or  when  the  membrane  is  very  tense. 
If  the  septum  is  tightly  stretched  the  elasticity  of  the  struc- 
ture separates  the  edges  of  the  tear,  giving  the  appearance  of 
a  certain  loss  of  substance. 

Following  the  introduction  of  chemical  irritants,  the  de- 
struction  depends  upon  tiic  activity  of  the  chemical  agent  in- 
stilled. 

We  have  purposely  omitted  the  cases  of  rupture  follow- 
ing severe  injuries  of  the  cranium,  since  here  the  aural  affec- 
tion is  of  but  slight  imjiortance  in  comparison  with  the  frac- 
ture of  the  base  of  the  skull  or  the  cerebral  concussion.  The 
drum  membrane  in  these  cases  may  be  injured  either  by  a 
blow  upon  the  side  of  the  head,  which  suddenly  compresses 
the  air  within  the  canal,  or  by  a  blow  upon  the  skull  which, 
by  the  force  of  impact,  subjects  the  bony  ring  to  great  pres- 
sure at  one  point,  and  causes  it  to  yield  slightly,  rupturing 
the  attached  membrane. 

Where  the  middle  ear  becomes  secondarily  involved,  the 
pathology  does  not  differ  from  that  of  a  middle-ear  inflamma- 
tion from  any  other  cause  except  in  the  fact  that  it  is  usually 
purulent. 

Symptomatology. — When  the  drum  membrane  has  been 
torn,  tile  iirst  s\nij)tom  is  severe  pain,  referred  to  the  deeper 


SYM1TO.MATOLO(;Y  — DIAGNOSIS. 


^93 


part  of  the  origan.  Coincident  with  this  there  is  a  very  de- 
cided impairnicnt  in  hearing  and  the  development  of  loud 
subjective  noises.  X'ertigo  ordinarilv  t)ccurs  following  a  blow 
upon  the  ear.  but  this  is  due  rather  to  a  sudden  increase  in 
labyrinthine  tension  than  to  rupture  oi  the  niembrana  tym- 
pani.  V^ery  soon  the  patient  is  ct)nscious  of  a  watery  dis- 
charge within  the  meatus,  and  the  acute  pain  which  was  pres- 
ent immediatelv  after  the  injury  becomes  dull,  throbbing,  and 
more  diffuse.  U[)on  blowing  the  nose  the  attention  is  at  once 
attracted  by  the  passage  of  the  air  through  the  car,  with  the 
production  of  a  high-pitched  whistling  sound.  If  secretion  is 
present  the  high-pitched  note  is  followed  bv  bubbling  sounds 
as  the  air  passes  through  the  fluid.  Where  the  rent  is  large, 
the  pain  is  usually  of  shorter  duration  than  when  but  a  small 
opening  is  present.  The  reason  of  this  is  that  the  copious 
serous  transudation  which  immediately  follows  the  injury 
finds  a  ready  means  of  exit  from  the  tympanic  cavity,  and 
produces  less  pressure  u|»on  the  parts  than  where  but  a  small 
opening  exists. 

The  subsequent  i)r()gress  ol  the  case  will  vary  according 
as  the  middle  ear  is  or  is  not  involved.  In  the  fir.'^t  instance 
a  rather  long-continued  suppurative  i)r()cess  not  infrequently 
follows,  while,  if  the  Ivmpanum  escapes,  the  rent  of  its  outer 
wall  mav  close  perfectlv  in  a  few  days,  leaving  no  symjitoms 
behind. 

Diagnosis. — A  recent  rupture  is  easily  made  out  on  exami- 
nation, its  ii  regular  contour  being  marked  by  a  delicate  line 
where  the  rupture  is  linear  (Fig.  91),  or  by  an 
apparent  loss  of  substance  over  the  affected 
region  where  a  circular  opening  is  present. 
Through  this  opening  the  mucous  lining  of  the 
middle  ear  appears  red  and  congested,  throw- 
ing a  bright  reflex  back  to  the  eye  from  the 
moisture  upon  the  inner  tympanic  wall.  The 
history  of  traumatism  in  the  region  of  the  ear, 
or  of  any  injury  to  the  skull,  followed  by  an 
aural  discharge,  should  lead  to  a  careful  ex- 
amination for  anv  evidence  of  injury  to  the  drum  membrane. 
Where  the  rent  occurs  close  to  the  margin  of  the  ring  it  may 
escape  recognition,  unless  the  entire  line  of  attachment  of  the 
membrane  be  inspected.  Wounds  in  Shrapnell's  membrane 
are  less  easilv  recognized   than  those  in  mcmbrana  vibrans, 


1"  ic.  91. — Linear 
rupture  of  the 
membrana  tym- 
pani. 


294    WOUNDS  AND  INJURIES  OF  THE  MEMBRANA  TYMPANI. 

owing  to  the  natural  flaccidity  of  this  part.  Evidences  of  a 
previous  rupture  are  the  presence  upon  the  surface  of  the 
drum  membrane  of  minute  blood  clots,  corresponding  in 
position  to  the  outline  of  the  rent,  and  the  coexistence  of 
delicate  radiating  vessels  along  this  line  which  impart  a  slight 
pinkish  tinge  to  the  affected  area.  These  vessels  become  visi- 
ble, owing  to  the  increased  vascularity  incident  to  the  repara- 
tive process.  The  presence  of  minute  blood  clots  in  the 
meatus  also  points  to  a  previous  injury.  These  appearances 
are  of  practical  value  only  in  medico-legal  cases,  where  we 
may  be  called  upon  to  determine  the  effect  on  the  ear  of  a 
previous  injury. 

Prognosis. — An  opening  made  into  tne  tympanic  cavity 
as  a  surgical  procedure  is  one  of  the  simplest  operative  meas- 
ures employed.  It  is  quite  different,  however,  if  the  open- 
ing occurs  as  the  result  of  an  accident,  when  the  meatus  may 
contain  an  abundance  of  infectious  material,  which  thus  gains 
access  to  the  mucous  lining  of  the  tvmpanum  ;  here  it  is 
easily  absorbed  and  produces  characteristic  results. 

On  account  of  this,  an  accidental  rupture  of  the  mem- 
brana  tympani  at  the  hands  of  the  surgeon  in  attempting  to 
reuKn-e  a  foreign  body,  either  with  the  svringe  or  curette,  is 
seldom  followed  by  untoward  results  ;  while  the  same  acci- 
dent inflicted  at  the  hand  of  the  patient  might  lead  to  fatal 
consequences.  In  the  one  case,  if  proper  precautions  have 
been  taken,  the  parts  are  in  a  thoroughly  aseptic  condition 
before  the  traumatism  has  occurred,  and  hence  no  infection 
follows,  while  the  reverse  is  true  in  the  latter  instance. 

In  general,  the  prognosis  both  for  the  ultimate  closure  of 
the  opening  and  the  restoration  of  the  power  of  audition  is 
fairly  good,  if  the  case  comes  under  observation  before  a 
chronic  purulent  inflammation  has  supervened.  If  this  has 
occurred,  the  result  will  depend  upon  the  condition  of  the 
parts  as  revealed  by  the  examination,  independent  of  the 
cause  which  has  produced  it. 

Treatment. — As  the  surgeon,  no  matter  how  expert,  will 
occasionally  wound  the  membrana  tvmpani,  no  instrument 
should  be  inserted  into  the  meatus  before  this  channel  has 
been  thoroughly  cleansed.  Even  in  removing  foreign  bodies 
by  means  of  the  svringe,  the  solution  employed  should  be 
antiseptic  in  character,  in  view  of  the  fact  that  the  tympanum 
may  be  accidentally  entered.     Under  these  conditions  it  is 


TREATMENT. 


295 


only  necessary  to  dry  the  parts  lii^htly  with  cotton,  dust  a 
little  boric  acid  along  the  margins  of  the  wound,  and  occlude 
the  meatus  with  a  pledget  of  sterilized  cotton.  A  little  se- 
rous discharge  may  follow,  in  which  case  the  patient  is  direct- 
ed to  change  the  cotton  as  frequently  as  it  becomes  saturated. 
No  other  treatment  is  necessary,  the  parts  resuming  their 
normal  condition  in  from  twelve  to  twenty-four  hours,  even 
when  vcrv  free  serous  discharge  has  suj>ervcncd. 

When  seen  at  a  later  jjeriod,  or  in  cases  where  it  is  prob- 
able that  infection  has  taken  place,  local  bloodletting  from 
the  region  in  front  of  the  tragus  may  abort  the  intlanmiation. 
If  the  opening  through  the  drum  membrane  is  exceedingly 
minute,  and  the  middle  ear  contains  a  large  amount  of  fluid, 
the  wisest  plan  is  to  make  a  free  incision  through  the  drum 
membrane,  at  the  same  time  incising  the  opposite  internal 
wall  of  the  tympanum.  This  evacuates  the  contents  of  the 
cavity  and  depletes  the  vessels  ii|)on  its  inner  wall.  The 
measure  is  followed  almost  invariably  bv  a  j>rompt  disap- 
pearance of  the  symjttoms,  the  wound  closing  in  from  twenty- 
four  to  forty-eight  hours.  We  sometimes  meet  with  cases  in 
which  Nature  has  already  sealed  the  opening  by  the  deposit 
of  a  small  blood  clot  upon  the  external  surface  of  the  drum 
membrane.  No  attempt  should  be  made  to  remove  this  un- 
less there  is  severe  pain,  as  healing  invariably  takes  place  if 
the  clot  is  allowed  to  remain.  Interference  with  it  may  pos- 
sibly infect  the  cavity  and  be  followed  by  severe  inflammation 
of  the  middle  ear.  Acute  or  chronic  otitis  media  following 
the  accident  calls  for  the  treatment  indicated  under  the  dis- 
cussion of  these  diseases. 


///.    DISEASES   OF   THE  MIDDLE  EAR. 

The  entire  middle  ear,  from  the  pharyngeal  orifice  of  the 
Eustachian  tube  to  the  inner  surface  of  the  membrana  tym- 
pani,  is  covered  with  mucous  membrane;  this  is  supplied  with 
glandular  structures,  in  some  parts  very  richly,  while  in  other 
parts  they  are  rather  sparsely  distributed,  for  the  purpose  of 
keeping  the  membrane  moist. 

The  pathological  processes  met  with  here  may  involve 
either  the  entire  region  or  some  single  portion  of  it.  Consid- 
erable confusion  exists  at  present  in  the  classification  of  dis- 
eases of  the  middle  ear,  and  manv  cases  in  which  the  Eustachi- 
an canal  alone  is  affected  are  classified  as  cases  of  otitis  media, 
while,  on  the  other  hand,  certain  manifestations  within  the  tym- 
panum dependent  not  upon  inflammatory  changes,  but  upon 
certain  conditions  of  the  blood  vessels  distributed  to  the  parts, 
are  also  considered  under  the  same  title.  It  should  be  remem- 
bered that  the  fluid  effused  in  a  simple  inflammation  of  a  mu- 
cous membrane  is  an  increased  amount  of  the  normal  secre- 
tion of  the  membrane,  and  nothing  more.  The  presence  of  a 
purulent  effusion  as  the  primary  result  of  such  an  inflamma- 
tory change  in  a  cavity  lined  with  mucous  membrane  is  im- 
possible ;  in  order  that  the  fluid  shall  be  purulent,  infection 
must  take  place  from  the  outside,  or  the  inflammation  must 
be  infectious  from  the  first,  and  involve  not  only  the  mucous 
membrane,  but  the  underlying  connective-tissue  structures. 
The  affections  in  which  the  mucous  membrane  alone  is  in- 
volved have  been  denominated  as  catarrh  of  the  middle  ear. 
From  the  derivation  of  the  term,  this  name  indicates  simply 
an  increased  amount  of  secretion.  Such  an  inflammatory  pro- 
cess may  involve  the  Eustachian  tube  alone,  giving  rise  to  tubal 
catarrh  or  catarrhal  salpingitis,  or  both  the  tube  and  the  tym- 
panum may  be  involved,  in  which  case  we  have  a  tubo-tym- 
panic  catarrh  or  salpingo-tympanitis.  In  this  last-named  dis- 
ease the  inflammatory  process  is  chiefly  confined  to  the  tube 
and  seldom  goes  beyond  the  stage  of  congestion,  changes  tak- 

(296) 


EXPLANATION    OF    PLATE   V. 

1.  Appearance  of  the  membrane  in  tubal  catarrh.  Exaggeration  of  an- 
terior and  posterior  folds.  Short  process  prominent.  Malleus  handle  fore- 
shortened (indicating  marked  retraction  I.  Light  reflex  lost.  No  evidences  of 
congestion  in  membrane  or  tympanum. 

2.  The  normal  membrana  tympani.  The  congestion  along  the  posterior 
border  of  the  manubrium  was  due  to  the  i)roIonged  presence  of  the  speculum 
in  the  canal. 

3.  Otitis  media  purulenta  residua,  with  caries  of  the  malleus  and  incus. 
There  is  a  small  perforation  above  the  short  process.  The  malleus  handle  is 
adherent  to  the  internal  tympanic  wall,  which  is  partially  covered  with  a  non- 
secreting  membrane.  This  is  wanting  posteriorly  over  the  niche  of  the  round 
window,  and  anteriorly  over  the  entrance  to  the  Eustachian  tube. 

4.  Purulent  otitis  media,  with  extensive  destruction  of  the  membrana 
vibrans  and  displacement  of  the  ossicles.  The  long  arm  of  the  incus,  the 
posterior  crus  of  the  stapes,  and  the  niche  of  the  round  window  are  visible. 

5.  Chronic  catarrhal  otitis  media  (hypertrophic  formi.  Malleus  shaft 
rotated  upon  its  long  axis  and  apparently  increased  in  breadth.  There  are 
several  areas  of  calcification  in  the  membrane. 

6.  Serous  effusion  in  middle  ear,  with  congestion  of  membrana  flaccida. 
The  level  of  the  fluid  is  distinct.  This  condition  is  often  present  in  tubo- 
tympanic  congestion. 


(296  a) 


PLATE   V. 


4. 


Dr.  W.  A.  Ho/den,  ad.  nat.  del. 


EXI'I.ANA  I  ION    C)l-     I'l.ATK    VI. 

7  Chronic  catarrhal  otitis  media  (hvperplastic  changes  subsequent  to 
hypertrophic  inHammationi.  Membrane  retracted.  Malleus  handle  fore- 
shortened, and  apparently  narrow  from  rotation  upon  long  axis.  Adhesions 
beneath  iriembrana  flaccida.  as  shown  by  depression  above  short  process. 

8.  Retraction  of  membrana  tympani.  with  slight  foreshortening  of  the 
malleus  handle.  This  appearance  is  often  obsened  in  |)atients  with  enlarge- 
ment of  the  pharyngeal  tonsil,  who  suffer  from  repeated  attacks  of  tubal  or 
tubo-tympanic  congestion.  The  membrane  becomes  relaxed  and  attenuated, 
and  smks  inward  upon  the  internal  tympanic  wall,  so  that  the  long  arm  of 
the  incus  and  the  incudo-stapedial  articulation  are  easily  recognized. 

9.  Intense  congestion  of  membrana  flaccida  and  of  manubrial  plexus. 
The  membrana  vibrans  normal  in  parts  not  adjacent  to  extensive  vascular 
picxu.:.  Such  an  appearance  characterizes  the  first  st.ige  of  acute  purulent 
otitis  media. 

10.  .Acute  purulent  otitis  media,  with  bulging  of  membrana  flaccida  and 
displacement  of  adjacent  wall  of  meatus.  The  membrana  vibrans  is  partially 
hidden,  but  the  portion  visible  is  normal  in  color. 

11.  Chronic  purulent  otitis  media.  There  is  a  perforation  above  the  short 
process,  through  which  a  mass  of  granulation  tissue  protrudes.  The  mem- 
brana vibrans  is  wanting  over  the  tympanic  orifice  of  the  Eustachian  lube. 

12  Otitis  media  purulenta  residua.  Perforation  in  posterior  inferior  quad- 
rant. The  appearance  is  characteristic  of  acute  congestion  as  it  occurs  in 
these  cases.  The  turgescence  is  confined  to  the  regions  richly  supplied  with 
blood  vessels. 


PUTE   VI. 


10. 


11 


12. 


Dr.  W.  A.  Holden,  ad,  nat.  del. 


I'RKLIMINARV    t)BSP:R\'AT10NS.  ^O" 

ing  place  in  the  cavity  of  the  middle  ear  beins:  almost  entirely 
secondary  to  this  and  depending-  upon  the  physical  condition 
of  reduced  pressure  within  the  tympanum,  due  to  closure  of 
the  Eustachian  canal.  The  disease  is  reallv  salping^itis.  which 
secondarily  has  given  rise  to  certain  physical  changes  within 
the  drum  cavity  discernible  upon  otoscopic  examination,  and 
scarcely  deserves  recognition  as  an  individual  affection.  The 
separation  of  these  two  varieties  is  made  more  for  convenience 
in  classification  than  for  any  other  reason. 

In  other  instances  the  tym|»anum  is  the  primary  seat  of  a 
superficial  inflammation  with  no  involvement  of  the  connective- 
tissue  framework.  In  such  cases  the  changes  are  usually  con- 
fined to  the  lower  j)ortion  of  the  tympanic  cavity  or  to  the 
atrium.  The  ej)itymi)anic  space  is  not  involved,  and  the  in- 
flammatc^ry  process  results  in  the  pouring  out  of  an  increased 
amount  of  normal  secretion,  which  fills,  more  or  less  com- 
pletely, the  middle  ear.  The  mucous  membrane  covering  the 
internal  surface  of  the  mcmbrana  tvmpani  particij)ates  in  the 
process,  and  the  mcmbrana  may  be  so  infiltrated  as  to  rup- 
ture from  the  increased  pressure  caused  by  the  pent-u[)  secre- 
tion, riie  rupture  of  the  membrane  in  such  a  case  depends 
not  so  much  ujion  a  deep-seated  inflammatory  process  as  upon 
the  increased  j)ressure  to  which  the  membrane  is  subjected 
from  the  secretion  within  the  cavity,  although  in  severe  cases 
it  is  probable  that  the  entire  thickness  of  the  membrane  is 
involved  on  account  of  the  free  anastomosis  between  the 
vessels  of  the  inner  and  outer  layers.  After  perforation  has 
taken  place  thi^  form  of  inflammation  may  become  changed 
in  character  from  the  infection  of  the  dischaifje  from  with- 
out.  after  which  it  runs  the  ty[)ical  course  of  a  jnirulent  in- 
flammation. 

Such  are  the  changes  present  in  those  cases  where  a  sim- 
ple catarrhal  inflammation  occurs  within  the  middle-ear  tract. 
Both  in  tubo-tympanic  catarrh  and  in  acute  catarrhal  inflam- 
mation of  the  middle  ear  we  may  have  a  solution  of  continuity 
in  the  drum  membrane  ;  in  the  tubo-tympanic  form  this  rup- 
ture is  due  simply  to  the  pressure  of  the  fluid  with  which  the 
cavity  is  filled.  It  is  probable  that  rupture  never  occurs  in 
these  cases  if  the  membrane  is  not  atroj)hic  from  a  previous 
pathological  process.  This  fluid  is  ncjt  the  result  of  inflam- 
mation, but  of  a  serous  transudation  simply  from  the  overdis- 
tendcd    vessels.      The   fluid   collects    in    the  atrium    although 


298  DISEASES    OF    THE    MIDDLE    EAR. 

transudation  may  take  place  from  the  numerous  reduplica- 
tions in  the  upper  part  of  the  cavity,  the  fluid  entering  the 
atrium  in  obedience  to  the  laws  of  gravity.  In  acute  catarrhal 
tympanitis  the  transudation  is  of  inflammatory  origin,  and 
this  inflammatory  process  may  be  a  factor  of  some  impor- 
tance in  causing  the  rupture  of  the  membrane,  although  it 
is  certainly  not  the  principal  one.  Here  the  atrium  alone  is 
affected,  although  the  tympanic  vault  mav  be  involved  sec- 
ondarily from  subsequent  infection  of  the  discharge. 

Where  the  inflammation  is  purulent  from  the  start  we  have 
those  structures  primarily  involved  which  are  richly  supplied 
with  connective-tissue  elements.  By  recalling  the  anatomy  of 
the  tvmpanic  cavity  we  remember  that  the  vault  of  the  tvm- 
panum  contains  numerous  duplicatures  of  mucous  membrane, 
these  being  so  fully  developed  in  some  instances  as  to  com- 
pletelv  fill  the  entire  epitvmpanic  space;  the  connective-tissue 
framew(^rk  of  these  folds  presents  a  favorable  site  for  the 
growth  of  the  bacteria  of  suppuration.  When  infection  of 
this  tissue  occurs  we  have  an  inflammation  set  up  which  dif- 
fers in  no  respect  from  a  cellulitis  in  any  other  portion  of  the 
body  ;  tissue  necrosis  takes  place  quite  rapidly,  and  the  secre- 
tion resulting  from  the  inflammation  is  purulent  in  character 
from  the  outset.  The  fluid  products  find  exit  either  into  the 
atrium  and  then  into  the  canal,  or  the  membrana  flaccida  may 
be  ruptured  and  an  outlet  afforded  in  this  way,  or  the  secre- 
tion mav  find  its  way  into  the  mastoid  cells  or  even  into  the 
cranial  cavitv  when  egress  in  other  directions  is  prevented. 
Purulent  inflammation  occurs,  as  we  should  expect,  in  the 
more  severe  tvpes  of  acute  infectious  diseases  such  as  scarla- 
tina, diphtheria,  variola,  general  pya^mic  infection,  etc.  As 
above  stated,  it  may  occasionally  follow  a  simple  catarrhal  in- 
flammation by  infection  of  the  discharge  and  subsequent  in- 
oculation of  the  connective  tissue  [n  the  tympanic  vault 
through  this  secretion. 

Under  the  forms  of  chronic  inflammation  involving  the 
portion  of  the  conducting  mechanism  under  consideration,  we 
have  those  resulting  directly  either  from  a  previous  simple 
catarrhal  inflammation  or  from  a  purulent  process. 

We  include  in  this  group  those  cases  which  give  the  history 
of  repeated  attacks  of  acute  middle-ear  inflammation,  but  in 
whom  the  membrana  tvmpani  is  not  perforated.  Other  cases 
present  in  which  the  membrana  tvmpani  has  been  destroyed 


rKLLl.MlNAKV    OBSLRX'A  TIONS. 


299 


over  a  small  or  lar^^c  area  and  a  permanent  perforation  re- 
mains. These  ai^ain  divide  themselves  into  cases  in  which 
the  discharge  still  continues  after  the  acute  disease  has  run 
its  course,  and  those  in  which  the  residue  of  the  former  at- 
tack remains,  the  affection  having  either  ceased  spontaneously 
or  vielded  to  treatment,  restitution  ot  the  necrosed  parts  not 
having  taken  place. 

A  third  class  of  cases  comj)rises  that  varictv  where  the  in- 
nainiiKilion  is  chronic  from  its  inccjdion  and  is  characttiized 
bv  a  deposit  of  new  tissue.  [0  this  we  give  the  term  hyper- 
plastic inflammation.  Although  we  may  hnd  this  condition 
where  a  previous  purulent  inflammation  has  existeil  resulting 
in  local  necrosis,  it  is  usuallv  met  with  where  no  such  loss 
has  taken  place.  No  sharp  dividing  line  can  be  drawn  be- 
tween this  variety  and  those  following  an  acute  catarrhal  in- 
flammation which  has  failed  to  resolve,  and  to  whicii  the 
term  hvpertro|)hic  is  applied. 


CHAPTER   XVII. 

TUBAL   CONGESTION,    OR   TUBAL   CATARRH. 
(Acute  Salpingitis.     Eustachian  Catarrh.) 

.Etiology. — This  affection  of  the  Eustachian  tube  usually 
arises  from  an  acute  coryza  or  an  acute  naso-pharvnj^itis, 
although  it  mav  be  met  with  as  a  primary  affection  from 
exposure  to  cold.  Occasionally  it  complicates  light  attacks 
of  the  exanthemata  in  voung  adults.  It  may  depend  upon 
the  entrance  of  some  irritating  fluid  into  the  Eustachian  tube 
while  bathing,  or  in  using  the  nasal  spray.  Rarely  it  follows 
a  blow  upon  the  external  surface  of  the  body  in  this  region. 
The  chief  predisposing  cause  is  some  obstructiye  lesion  of 
the  nose  or  naso-pharynx.  The  presence  of  adenoid  yegeta- 
tions  is  a  particularly  potent  factor  in  its  causation,  since 
these  masses  easily  become  engorged  with  blood,  causing 
yenous  hyperasmia  of  the  walls  of  the  tube,  narrowing  or  com- 
pletely closing  its  lumen.  At  the  same  time,  the  presence  of 
this  soft  tissue  in  the  yault  of  the  pharynx  afTords  lodgment 
to  pathogenic  bacteria  inhaled  during  the  act  of  inspiration, 
from  which  locality  tiiey  easily  find  their  way  into  the  canal. 
Imjiaircd  general  health,  no  doubt,  renders  one  more  liable 
to  the  disease. 

Pathology. — The  pathological  conditions  are  to  be  con- 
sidered under  two  heads : 

First,  the  actual  changes  present  in  the  tubal  mucous 
membrane. 

Second,  the  changes  occurring  in  the  middle  ear  depend- 
ent upon  the  obliteration  of  the  tubal  lumen. 

Within  the  tube  the  condition  is  essentially  one  of  simple 
venous  hyperasmia,  or  the  membrane  may  be  the  seat  of  a 
very  mild  inflammation  following  the  venous  engorgement. 
The  mucous  membrane  becomes  swollen  and  flabby,  the  walls 
of  the  tube  lying  in  contact  with  each  other  and  adhering 
closely  on  account  of  viscid  secretion.     The  first  change  of 


SYMPTOMAIOLOGY.  3OI 

venous  hypera^Miiia  results  in  a  transudation  of  the  fluid  ele- 
ments of  the  blood  from  the  increased  pressure.  When  the 
process  becomes  fully  developed,  the  secretion  is  thick,  tena- 
cious, i^lairy,  white  in  color,  and  by  its  presence  may  occlude 
the  channel  completely.  The  changes  are  usually  most  marked 
in  the  cartilaginous  part  of  the  tube,  the  osseous  segment  be- 
ing but  little  afTected. 

When  the  Rustachian  canal  is  obstructed  from  any  cause 
the  air  c(jntained  within  tlie  tymi)anic  cavity  disappears  quite 
rapidly  from  absorption.  This  results  in  diminished  atmos- 
pheric pressure  within  the  tympanum,  and  a  crowding  inward 
of  the  drum  membrane  and  the  entire  ossicular  chain  by  the 
external  atmospheric  pressure.  If  tiie  canal  remains  closed 
sufficiently  long,  we  shall  find  the  drum  membrane  so  dis- 
placed that  it  touches  the  opposite  internal  tympanic  wall  in 
the  region  of  the  tip  of  the  long  process  of  the  malleus.  At 
its  upj)er  and  lower  poles  its  firm  attachment  prevents  dis- 
placement. 

Symptomatology. — An  attack  of  this  character,  occurring 
in  the  couisc  ol  an  ordinary  cold  in  the  head,  is  usually  char- 
acterized by  a  rather  sudden  onset  of  the  symptoms.  The 
patient  complains  of  a  feeling  of  stuffiness  or  heaviness  in  the 
ears,  as  though  the  external  meatus  were  occluded  by  a  for- 
eign body,  one  of  the  most  characteristic  symi)toms  being  the 
desire  to  insert  the  hnger  into  the  meatus  in  order  to  "clear 
the  ear,"  as  the  patient  expresses  it.  This  mani|)ulati()n  is 
sometimes  attended  bv  momentary  relief  from  the  exhaus- 
tion of  the  air  within  the  meatus  when  the  finger  is  suddenly 
witiulrawn.  Sometimes,  in  addition  to  this  feeling  of  discom- 
fort, there  is  a  sensaticjn  of  actual  pain  referred  to  the  upper 
part  of  the  pharynx  or  the  region  of  the  tonsil.  In  rarer  in- 
stances this  pain  is  complained  of  in  the  region  of  the  larynx, 
the  sensati(jn  being  as  though  a  foreign  body  had  become 
lodged  at  the  root  of  the  tongue.  Accompanying  this,  there 
is  some  pain  radiating  upward  toward  the  ear,  but  when 
closely  questioned  we  find  that  no  actual  pain  is  prr<iriit  in 
the  ear. 

The  hearing  is  considerably  impaired,  the  diminished  audi- 
tion seeming  more  prominent  from  the  sudden  onset  of  the 
attack.  Subjective  noises  are  almost  always  present,  and  may 
be  exceedingly  distressing.  They  are  most  frequently  high- 
pitched  in  character,  and  in  plethoric  subjects  may  increase 


302     TUBAL  CONGESTION.  OR  TUBAL  CATARRH. 

in  intensity  with  each  cardiac  systole.  Disturbances  of  equi- 
librium, from  the  sudden  increase  of  labyrinthine  pressure, 
may  be  met  with,  although  their  occurrence  is  not  invariable. 
Among-  the  rarer  symptoms  to  which  the  affection  gives  rise 
is  a  feeling  of  heaviness  and  mental  torpiditv.  In  nervous 
subjects  the  anxiety  of  the  patient  as  to  the  sudden  impair- 
ment of  hearing  power  is  rather  characteristic.  The  sensa- 
tion of  heaviness  within  the  ears  may  not  remain  confined  to 
this  region,  but  may  be  complained  of  as  a  stiff,  numb  feeling 
extending  over  the  entire  side  of  the  head.  It  is  seldom  that 
both  sides  are  affected  to  the  same  degree,  although  examina- 
tion will  seldom  show  a  perfectly  normal  condition  in  the 
organ  which  the  patient  asserts  is  hcalthv. 

Occasionally  cases  are  met  with  in  which  an  attack  of  tubal 
congestion  follows  any  slight  exposure  to  cold.  While  not 
severe  enough  to  narrow  the  lumen  of  the  canal  to  an  extent 
which  interferes  sutificiently  with  audition  to  direct  the  atten- 
tion of  the  patient  to  the  ear,  the  subjective  symptoms  are 
very  pronounced.  They  consist  in  the  sensation  of  a  foreign 
body  in  the  pharvnx,  or  sometimes  of  an  acute  pain  at  the 
root  of  the  tongue,  occasionally  severe  enough  to  interfere 
with  deglutition.  The  patient  does  not  complain  of  the  ear, 
but  refers  all  the  symptoms  to  the  pharynx  or  larynx.  These 
manifestations  are  met  with  most  frequently  among  neurotic 
subjects,  and  the  attacks  may  be  repeated  at  short  intervals. 
Occasionallv  thev  occur  in  individuals  who  arc  not  neurotic, 
and  in  these  patients  the  symptoms  arc  more  acute,  and  close 
questioning  will  usuallv  elicit  a  history  of  a  slight  impair- 
ment of  audition. 

Diagnosis.— A.  lliysical  Exaviination. — An  inspection  by 
reflected  light  reveals  the  drum  membrane  drawn  inward 
towards  the  internal  tvmpanic  wall,  for  which  reason  the  in- 
ferior segment  seems  abnormallv  broad  from  above  downward, 
while  at  the  same  time  the  transverse  diameter  of  this  seg- 
ment seems  to  be  increased  (Fig.  92).  The  handle  of  the  mal- 
leus is  foreshortened,  the  short  process  is  prominent  and  ap- 
pears lighter  than  normal,  and  in  some  cases  it  may  be  impos- 
sible to  make  out  the  contour  of  the  manubrium,  owing  to  the 
extreme  degree  of  retraction,  the  shaft  being  entirely  hidden 
behind  from  the  prominent  short  process.  Both  the  anterior 
and  the  posterior  folds  are  exaggerated,  the  annulus  tendino- 
sus  is  prominent,  and  the  membrana  flaccida  may  participate 


uiac;nosis. 


303 


in  these  changes,  being  drawn  inward  upon  the  neck  of  the 
malleus  and  closely  applied  to  it,  although  this  latter  condi- 
tion is  not  ordinarily  present.  The  color  of  the  membrane  is 
normal,  its  lustre  is  preserved,  and  the  light 
reflex  is  either  absent,  displaced,  or  multi- 
ple. The  stretching  to  which  the  parts  have 
been  subjected  causes  the  membrane  to  ap- 
pear thinner  than  normal,  and  the  under- 
lying intratvmpanic  structures  mav  be  clear- 
Iv  discerned   through   it.      In  the  upper  and     i""-  92  — Keuaction 

,  ,  ,  of  mcmbran.i   tvm- 

postenor  segment  we  are  otten  able  to  recog-  pani  from  closure 
nize  the  lon^r  process  of  the  incus,  the  in-  "^'^  ^^^  Eustachian 
cudo- stapedial  articulation,  the  posterior 
crus  of  the  stapes,  and  sometimes  the  tendon  of  the  stapedius 
muscle.  The  niche  of  the  round  window  may  also  be  visible. 
The  lining  membrane  of  the  tvmpanum,  as  viewed  through 
this  thin  covering,  presents  no  evidences  of  congestion.  The 
physical  appearances  are  due  entirelv  to  the  diminution  of 
atmospheric  pressure  witiiin  the  t\  rnpanic  cavitv,  this  region 
itself  being  unaffected. 

If  the  ear  is  inflated,  either  bv  means  of  the  Eustachian 
catheter  or  bv  the  Politzer  method,  the  auscultation  tube  be- 
ing emploved  to  furnish  us  with  information  concerning  the 
condition  of  the  parts,  we  shall  find  that  the  canal  is  opened 
with  difficulty,  the  air  either  not  entering  the  middle  ear  at  all 
or  only  after  several  attempts  at  inflation.  When  the  cathe- 
ter is  used,  the  first  few  compressions  oi  the  bulb  result  in 
the  production  of  a  harsh,  low-pitched,  rasping  sound,  which 
we  recognize  as  originating  in  the  vault  of  the  pharvnx,  and 
not  depending  upon  the  entrance  of  air  into  the  middle  ear. 
This  is  caused  either  bv  the  current  being  f(jrced  through  the 
thick  viscid  secretion  with  which  the  parts  are  covered,  or 
by  impinging  directly  upon  the  mucous  membrane  of  the 
passage,  which  from  the  oedema  is  thrown  into  irregular  folds 
and  deflects  the  current  of  air  from  its  original  direction.  As 
inflation  is  continued  these  pharyngeal  sounds  disappear,  and 
the  air  enters  the  tube,  either  from  the  dislodgment  of  the 
mucus  or  from  the  displacement  of  the  folds  in  the  mucous 
membrane  bv  manipulation  of  the  catheter.  Within  the  tube 
the  current  may  meet  an  obstruction,  either  from  an  agglu- 
tination of  the  walls  of  the  tube  or  from  the  lodgment  of  a 
mucous  plug  at  the  isthmus.     When  familiar  with  the  auscul- 


304     TUBAL  CONGESTION.  OR  TUBAL  CATARRH. 

tatory  signs  we  recognize  that  the  sound  produced  by  the 
insufflated  air  is  nearer  the  ear,  and  is  of  a  less  harsh  charac- 
ter than  when  the  obstruction  is  at  the  pharyngeal  orifice, 
while  the  sensation  of  the  sound  being  produced  close  to  our 
own  ear  is  wanting.  At  last  we  recognize  the  entrance  of  the 
current  into  the  tympanic  cavity,  the  quantity  of  air  entering 
being  at  first  small  and  the  sound  produced  by  its  passage 
being  consequently  high-pitched.  If  the  swelling  is  exces- 
sive, the  entrance  of  the  air  into  the  tympanum  is  irregular, 
instead  of  occurring  freely  with  each  compression  of  the  bulb. 
When  at  length  the  lumen  has  been  sufficiently  cleared  to 
permit  the  free  entrance  of  the  current,  the  sudden  replace- 
ment of  the  drum  membrane  to  its  normal  position  is  recog- 
nized by  the  examiner  by  the  occurrence  of  a  sharp,  almost 
metallic  click,  as  the  membrane  is  forced  outward. 

B.  Functional  Examination. — Upon  testing  the  hearing,  we 
find  the  power  of  audition  for  the  whisper  markedly  reduced  ; 
tests  with  the  acoumeter  and  watch  will  also  show  reduction 
in  the  hearing  power,  although  to  a  relatively  less  degree 
than  to  the  voice.  The  lower  tone  limit  is  elevated,  in  the 
great  majority  of  cases  being  above  32  V.  S.,  and  sometimes 
two  octaves  higher  than  this.  The  uppier  tone  limit  is  fre- 
quently reduced,  or  it  may  be  normal.  When  reduced,  the 
change  is  caused  bv  pressure  upon  the  delicate  structures 
lying  in  the  lower  turn  of  the  cochlea.  The  bone  conduction 
is  augmented  especially  for  the  low  notes  of  the  scale,  Rinne's 
experiment  being  negative  for  the  lower  notes  and  a  reduced 
positive  result  being  found  as  we  ascend  the  musical  scale. 
The  vibrating  tuning  fork,  placed  upon  the  vertex  or  upon 
the  forehead,  is  referred  to  the  poorer  ear  in  almost  all  cases. 
These  reactions  may  be  considered  as  typical,  and  will  be 
found  in  a  very  large  majority  of  instances.  Certain  condi- 
tions may  exist,  however,  which  will  modify  them,  to  which 
attention  should  be  given.  In  patients  over  forty  years  of 
age  the  tuning  fork  may  not  be  lateralizcd  to  the  side  most 
affected,  and  the  bone  conduction  may  not  be  increased  in 
comparison  with  the  normal  standard.  A  similar  change  may 
be  found  upon  applying  Rinne's  test.  The  remarks  made  in 
the  chapter  on  Physiology  upon  the  diminution  of  bone  con- 
duction as  age  advances  explain  this  apparent  deviation 
from  the  classical  reactions.  When  the  patient  is  seen  very 
early,  and  before  much  retraction  of  the  mcmhrnna  tympani 


FUNCTIONAL    EXAMINATION.  305 

is  present,  we  may  find  that  the  jxiticnt  hears  the  lower  notes 
of  the  scale  fairly  well,  while  at  the  same  time  bone  conduc- 
tion is  greatly  diminished,  and  the  upper  tone  limit  lowered. 
This  is  probably  due  to  a  slight  rarefaction  of  the  air  within 
the  tympanum,  which,  according  to  Politzer,  instead  of  in- 
creasing labyrinthine  pressure,  reduces  it.  It  may  also  de- 
pend upon  the  particular  susceptibility  of  the  auditory  nerve 
to  mechanical  irritation,  causing  a  condition  of  hyperaesthesia, 
which  favors  the  perception  of  low  notes,  at  the  same  time 
reducing  bone  conduction. 

These  variations,  while  apparently  confusing,  in  no  way 
detract  from  the  value  of  the  functional  examination,  as  they 
indicate  the  existence  of  a  secondary  labyrinthine  condition. 
Tins  interference  with  the  perceptive  apparatus  is  perfectly 
amenable  to  any  treatment  which  will  remove  the  tympanic 
disturbance  upon  which  it  depends,  and  its  recognition  is  of 
importance  since  it  shows,  in  any  given  case,  a  particular  in- 
tolerance of  the  labyrinth  to  changes  in  pressure. 

It  is  not  unreasonable  to  supj)ose  that  in  any  of  these  cases 
of  sudden  closure  of  the  Eustachian  tube  the  labyrinth  sulTers 
a  certain  amount  of  traumatism,  the  same  as  when  the  ear  is 
exposed  to  the  influence  of  sudden  loud  sounds,  such  as  those 
produced  by  ex{)l(3sions,  etc.  It  is  a  well-known  fact  that 
under  these  conditions  a  train  of  symptoms  is  found  which 
we  consider  characteristic  of  concussion  of  the  labyrinth. 
In  the  same  manner,  the  sudden  increase  of  labyrinthine  pres- 
sure due  to  pressure  of  the  stapes  upon  the  perilymph  may 
cause  a  condition  of  hypera;sthesia  of  the  auditory  nerve,  and 
change,  to  a  marked  degree,  the  reactions  found  on  func- 
tional examination.  When  this  occurs  the  case  is  one  of  laby- 
rinthine disease,  acute  in  character,  and  readily  amenable  to 
treatment,  and  is  due  to  the  sudden  and  absolute  closure  of 
the  Eustachian  tube.  Our  functional  examination  reveals 
this  labyrinthine  condition,  and  should  not  be  condemned  be- 
cause it  enables  us  to  distinguish  a  complicating  labyrinthine 
lesion,  and  emphasizes  it  rather  more  than  the  tubal  stenosis. 
The  clinical  history  and  appearance  of  the  drum  membrane 
will  render  an  error  in  diagnosis  exceedingly  rare.  When 
the  auditory  nerve  is  in  a  condition  of  hypera^sthesia  the  per- 
ception of  low  tones  is  well  preserved,  and  it  may  happen 
that  the  lower  tone  limit  is  nr)t  elevated  to  the  degree  which 
we  should  expect  to  find  in  sudden  closure  of  the  Eustachian 


3o6     TUBAL  CONGESTION.  OR  TUBAL  CATARRH. 

tube.  Distressing  tinnitus  and  vertigo,  the  latter  being  espe- 
cially prone  to  occur  on  inflating  the  middle  ear,  together 
with  a  lowering  of  the  upper  tone  limit  before  inflation, 
render  the  diagnosis  sufficiently  clear. 

Prognosis. — Eustachian   catarrh   is  ordinarily  one  of  the 
simplest  affections  of  the  ear  which  it  falls  to  our  lot  to   meet. 
The  only  danger  to  the  function  of  the  oi-gan  lies  in  the  tend- 
ency to  a  recurrence  of  attacks  of  this  character.     We   have, 
then,  to  consider  not  only  the  outcome  of  the  attack  immedi- 
ately under  observation,  but  also  the  result  if  it  is  allowed 
to  repeat  itself  at  short  intervals.     An  attack  of  Eustachian 
catarrh   ordinarily  yields  to  treatment  in  from  five  to  four- 
teen days.     The   hearing  is  completely  restored  only  at  the 
end  of  several  weeks,  but  if  by  complete  restoration  we  mean 
an  absolutely  perfect  functional  condition  of  the  organ  in  the 
ordinary  acceptance  of  the  term,  the  patient  notices  nothing 
abnormal  about  the   car,  either  as  regards  the   integrity  of 
hearing  or  the  presence  of  subjective  noises  after  a  lapse  of 
five  to  fourteen  days.     After  an  individual  has  suflered  from 
several  attacks  of  this  affection  it  will  be  found  that  the  hear- 
ing gradually  becomes  impaired,  each  exacerbation  reducing 
it  somewhat,  at  first  impercej)tiblv,  but.  later  in  the  course  of 
the  disease   to  a  degree  distinctly  recognizable  both  by  the 
patient  and    bv  those  with   whom    he  is  brought   in   contact 
in    his  daily  vocation.      This  is  caused   by  the  development 
within  the  tympanic  cavity  of  a  slowly  progressive  inflam- 
matory process,  dependent  ujton  the  malposition  of  the  con- 
tained  parts   for  a   long  period   of    time.     When    the   drum 
membrane  is  indrawn  at  frequent  intervals  by  successive  at- 
tacks of   tubal  stenosis,  and  remains  in    this    position   for  a 
considerable  period,  it  becomes  stretched,  and  assumes  an  ab- 
normal   position    more    easily  than    does   the    normal    mem- 
brane.    The  tendon  of  the  tensor  tympanic  muscle  from  re- 
peated relaxation  becomes  shortened,  and  exerts  its  influence 
in  maintaining  the  irregularity  of  curvature  which  the  mem- 
brane   has  assumed.     This  shortening  of    the  tendon  of  the 
tensor  causes  the  tip  of  the  manubrium  to  press  upon  the 
internal  tympanic  wall.     This  source  of  mechanical  irritation 
gives  rise  to  an  inflammatory  process,  ultimately  resulting  in 
the  development  of  adhesions  in  other  parts  of  the  tympanic 
cavity,  and  producing  a  chronic  catarrhal  otitis  media.    Start- 
ing in  this  manner,  we  may  have  a  simple  hyperplastic  pro- 


TREATMENT— INFLATION. 


307 


cess  developed,  or  tlie  condition  so  much  dreaded  bv  the 
otologist  and  laity — sclerosis  within  the  tympanic  cavity. 
While,  therefore,  a  simple  tubal  catarrh,  if  left  to  itself,  will 
in  all  probability  disapj)car  at  the  end  of  a  certain  interval, 
we  should  never  lose  sij^ht  of  the  danjj^er  of  frequent  recur- 
rence, and  it  is  our  duty  not  only  to  relieve  the  single  attack, 
but  also  to  direct  our  elTorts  toward  preventing  a  repetition. 

Treatment. — The  treatment  of  the  affection  will  embrace 
measures  directed  to 

First,  the  acute  attack. 

Second,  prophylaxis. 

When  a  patient  suffers  from  the  disease  under  considera- 
tion our  first  efforts  are  to  relieve  the  subjective  noises,  the 
impairment  of  hearing  and  the  feeling  of  discomfort  within 
the  ear,  of  which  he  complains.  This  is  best  accomplished  by 
restoring  the  drum  membrane  to  its  normal  position  bv  some 
method  of  inflation,  in  adults  there  is  no  cpiestion  but  that 
the  employment  of  the  Eustachian  catheter  is  the  most  effect- 
ive means  at  our  (lis[iosal.  In  children,  the  Hustachian  tube 
being  relatively  short  and  catheterization  being  attended  by 
considerable  difficulty,  resort  may  be  iiad  to  inllatioii  bv  the 
Politzer  method.  When  tlie  catheter  is  usicl  we  shall  tmd,  as  a 
rule,  that  the  mucous  membrane  of  thenaresand  naso-phar\nx 
is  intensiU  tender,  owing  to  the  intlamin.it  ii  m  in  this  region 
which  has  caused  the  aural  disease.  I'o  overcome  this  and 
to  render  the  process  of  catheterization  less  disagreeal)lc  to 
the  i>.itient.  a  ten-pcr-cent  solution  of  cocaine  should  be  first 
sj)raved  into  the  anterior  nares,  the  ana:-sthesia  being  com- 
|)leted  bv  the  passage  of  a  cotton-tipped  probe  through  the 
nares,  the  cotton  having  been  saturated  with  cocaine  solu- 
tion. The  catheter  is  then  introduced  in  the  ordinary  man- 
ner, when,  by  compressing  the  inllating  bulb  several  times, 
the  membrane  is  replaced.  Care  should  be  exercised  in  jK'r- 
forming  this  manipulation  to  compress  the  bulb  gently  at  first, 
as  suddenly  filling  the  tympanic  cavity  with  air  at  this  period 
is  liable  to  cause  intense  dizziness,  and  the  j)atient  may  even 
fall  in  a  dead  faint.  By  performing  the  inflation  slowly,  and 
gradually  increasing  the  force  until  the  tube  becomes  perme- 
able, this  will  be  avoided.  If  the  patient  performs  the  act  of 
deglutition  at  the  moment  the  bulb  is  compressed,  the  air  en- 
ters the  cavity  more  easily.  The  relief  is  instantaneous  when 
the  malposition  of  the  membrane  is  corrected,  and  the  mental 


3o8     TUBAL  CONGESTION.  OR  TUBAL  CATARRH. 

depression  so  common  to  these  patients  disappeais  at  once. 
As  the  condition  will  undoubtedly  return  in  from  three  to 
twenty-four  hours  after  the  first  inHation.  and  from  the  sudden 
reappearance  of  the  symptoms  the  individual  may  consider 
himself  even  worse  than  before  treatment,  it  is  always  well 
to  call  attention  to  the  probability  of  this  recurrence.  It  is 
exceptional  that  a  single  inflation  will  permanently  relieve 
the  condition  and  the  consequent  symptoms.  Sometimes  the 
tube  is  so  tightly  closed  that  the  air  enters  the  middle  ear 
only  after  repeated  attempts  at  inflation.  When  this  is  the 
case  the  auscultation  tube  usually  reveals  the  cause.  This 
may  be  an  oedema  of  the  tubal  walls,  but  more  frequently  is 
the  lodgment  of  a  plug  of  thick  mucus  in  the  tubal  orifice, 
w'hich  complctelv  prevents  the  entrance  of  air.  This  ob- 
struction may  be  removed  by  wiping  the  tubal  mouth  with 
a  pledget  of  cotton,  the  extremity  of  the  cotton  carrier  be- 
ing curved  like  the  Eustachian  catheter.  After  this  has  been 
done  inflation  becomes  a  very  simple  matter.  The  drum 
membrane  being  replaced,  our  next  efforts  should  be  directed 
to  the  abnormal  condition  within  the  tube.  The  site  of  the 
greatest  oedema  is  usually  the  jiharyngeal  orifice,  a  part  easily 
accessible  to  instruments  intr()duc(?d  through  the  lower  mea- 
tus of  the  nose.  To  control  this  cvdcma  an  astringent  should 
be  ap))licd  to  the  tubal  mouth  bv  means  of  a  pledget  of 
cotton,  the  cotton  holder  being  bent  in  the  form  of  the  Eus- 
tachian catheter.  None  is  better  than  a  solution  of  nitrate  of 
silver  varying  in  strength  from  ten  to  tiiirtv  grains  to  the 
ounce.  The  degree  of  concentration  suited  to  any  particular 
case  can  be  learned  only  by  experiment,  but  in  general  the 
more  acute  the  process  the  stronger  the  solution  to  be  used. 
Concerning  the  application  of  vapors  to  the  Eustachian  tube, 
I  do  not  believe  this  procedure  to  be  wise  in  the  early  stages, 
as  their  action  usually  increases  rather  than  diminishes  the 
local  congestion.  The  application  of  astringents  seems  not 
only  more  rational,  but,  clinically,  is  followed  by  better  re- 
sults. The  operation  of  inflation  and  topical  applications  to 
the  pharyngeal  orifice  of  the  tube  should  be  repeated  at  first 
daily,  and  later,  as  improvement  becomes  more  marked,  the  in- 
terval should  be  prolonged  to  several  days,  until  complete  res- 
toration both  of  physical  condition  and  of  function  takes  place. 
In  some  cases  it  will  be  impossible  to  open  the  Eustachian 
tube  by  any  method  of  inflation.     Here  resort  must  be  had  to 


TRKATMi;  NT— BOLT,  IK— VAPORS. 


309 


the  Eustachian  bougie.  I  am  in  the  habit  of  using  for  this 
either  the  bougie  catheter  (shown  in  Fig.  93),  or,  in  the  ab- 
sence of  this,  the  ordinary  Eustachian  catheter,  through  which 
a  piece  of  No.  5  piano  wire  is  passed.  The  extremity  pro- 
truding from  the  catheter  is  roughened  slightly  witli  scissors 


/ 


Fig.  93. — Author's  liougie  catheter  for  Kustachian  tube. 


and  armed  with  a  j)ledget  of  cotton,  care  being  taken  to  wind 
this  so  tirmly  that  it  can  not  be  dis[)laced.  The  wire  is  then 
drawn  into  the  catheter  so  that  the  cotton-tipped  end  alone 
protrudes.  Remembering  that  the  diameter  of  the  Eustachian 
tube  yaries  from  three  quarters  of  a  millimetre  to  two  milli- 
metres, the  size  of  this  cotton  pletlget  should  certainly  not  ex- 
ceed the  last-named  dimension,  and  when  used  for  the  first 
time  it  is  well  to  make  it  considerably  smaller  than  this.  The 
opposite'end  of  the  wire  is  bent  at  a  right  angle  at  a  point  one 
inch  and  a  half  from  the  outer  funnel-shaped  extremity  of  the 
catheter.  This,  then,  enables  us  to  estimate  the  distance  that 
the  bougie  has  passed  into  the  tube  at  any  time.  The  bougie 
catheter  or  the  ordinary  Eustachian  catheter  armed  in  this 
way  is  introduced  in  precisely  the  same  manner  as  in  per- 
forming the  operation  of  inflation,  after  which  the  catheter  is 
firmly  fixed  in  position  by  the  fingers,  and  the  jnano  wire  is 
made  slowly  to  adyance  in  the  direction  of  the  Eustachian 
tube,  the  patient  being  recpiested  to  swallow  at  frequent  in- 
teryals,  both  to  relax  the  taucial  muscles  and  to  increase  as 
much  as  possible  the  diameter  of  the  canal.  After  the  instru- 
ment has  passed  about  an  inch  beyond  the  pharyngeal  orifice 
it  will  apparently  meet  an  obstruction  which  will  be  recog- 
nized as  the  istluiius  of  the  canal,  the  region  at  which  the 
lumen  is  normally  less  than  in  other  locations;  aside  from  this 
any  obstruction  encountered  constitutes  a  pathological  condi- 
tion. In  passing  the  instrument  beyond  such  an  obstruction 
the  greatest  gentleness  must  be  employed,  lest  the  mucous 
inembrane  of  the  canal  be  wounded  and  decidedly  uncomfort- 
able symptoms  superyene.  Most  frequently  in  tubal  catarrh 
the  obstruction  is  confined  to  the  cartilaginous  portion  of  the 
tube,  the  osseous  segment  remaining  free.     The  use  of  the 


3IO 


TUBAL  CONGESTION,  OR  TUBAL  CATARRH. 


cotton  pledget  as  a  dilator  has  a  twofold  advantage.  In  the 
first  place,  the  metal  parts  of  the  apparatus  ma)-  be  sterilized 
in  boiling  water,  and  if  the  pledget  is  formed  of  sterilized 
cotton  it  is  impossible  to  introduce  any  pathogenic  bacteria 
during  the  operation.  A  pledget  of  cotton  tightly  twisted  in 
this  manner  increases  in  volume  when  moistened.  If,  there- 
fore, an  obstruction  is  met  with,  and  the  mstrument,  after  en- 
gaging it,  is  allowed  to  remain  for  a  short  time,  considerable 
dilating  force  is  exerted  bv  the  absorption  of  moisture,  and 
a  twofold  advantage  gained.  C(jncerning  the  danger  of  the 
pledget  of  cotton  becoming  detached  in  the  lumen  of  the 
tube,  it  can  onlv  be  said  that  this  has  never  occurred,  and  if 
ordinarv  care  is  used  in  the  prcj^aration  of  the  apj)aratus  no 
such  accident  can  follow.  The  necessity  of  thoroughly  boil- 
ing the  instrument  immediately  before  using  it  can  not  be  too 
strongly  emphasized. 

Where  the  lining  membrane  resists  these  efforts  the  appli- 
cation of  astringents  to  the  mucous  membrane  beyond  the  ori- 
fice is  indicated.  These  mav  be  made  by  moistening  the  cot- 
ton pledget  previous  to  its  introduction  with  a  solution  of 
nitrate  of  silver  of  various  strengths,  beginning  with  a  weak 
solution,  about  five  to  ten  grains  to  the  ounce,  and  graduallv 
increasing  the  strength  until  the  desired  result  is  obtained. 
Under  no  condition  should  inflation  be  practiced  immediately 
after  the  introduction  of  a  bougie,  since  a  slight  abrasion  of 
the  mucous  membrane  mav  furnish  an  avenue  of  entrance  to 
tlie  air  and  submucous  cmphvsema  mav  result. 

When  the  conditic^n  fails  to  improve  at  the  end  of  ten  davs, 
stimulating  applications  in  the  form  of  vapors  mav  be  em. 
ployed  with  advantage.  The  object  of  such  applications  is 
temporarilv  to  increase  local  hvperaemia,  and,  by  means  of  this 
increased  blood  supplv,  to  restore  the  tone  of  the  parts  and 
cause  them  to  resume  their  normal  condition.  It  makes  but 
little  difference  what  vapor  is  emploved,  so  long  as  we  bear 
in  mind  the  object  to  be  attained.  Anv  preparation  which  is 
a  local  stimulant  arid  vaporizes  at  the  ordinarv  temperature 
may  be  used.  Tincture  of  benzoin,  oil  of  eucalyptus,  menthol, 
iodine,  camphor,  and  various  aromatic  oils  may  all  be  used 
with  success ;  the  vapor  of  alcohol,  of  ether,  or  of  chloroform 
is  also  efficacious.  The  best  method  of  exhibition  is  by  means 
of  a  device  bv  which  the  current  of  air  on  its  way  to  the 
tvmpanum  is  made  to   pass  over  the  volatile  substance,  thus 


TREATMKNT— PROrilYLAXlS.  3I  I 

becomiiii^  charged  with  a  certain  amount  of  the  volatile  prin- 
ciple. Either  Roosa's  or  Luca's  bulb,  or  the  bottle  devised 
by  Davton.  or  the  instrument  of  the  author  (see  Fi^.  94),  may 
be  emploved,  according  to  the  choice  of  the  operator. 


Fig  q4 -Author's  middle-car  vaporizer.  The  l>ottlc  is  f.t'cd  with  a  doi-.b'e  stop- 
cock, and  ether  air  or  medicated  vapor  can  be  insufflated  at  will  by  turning 
the  thumb-screw. 

If  the  author's  aj^paratus  is  emp;.'\(-ii.  it  is  well,  instead  of 
filling  the  reservoir  with  the  tUiid.  to  place  a  little  cotton 
saturated  with  the  prei)aration  to  be  used  within  this,  as  in 
the  event  of  the  accidental  breaking  of  the  reservoir  bv  a 
sudden  motion  of  the  patient  no  damage  is  done  to  the  gar- 
ments either  of  the  patient  or  of  the  physician. 

My  own  jirefcrencc  when  vapors  are  employed  is  first  to 
clear  the  tube  as  perfectly  as  possible  by  intlating  with  air 
alone,  after  which  the  inflation  is  continued  with  the  medi- 
cated air.  The  strength  of  the  application  varies  with  the  na- 
ture of  the  substance  and  with  the  condition  of  the  parts.  The 
menthol  and  camphor  may  be  used  in  alcoholic  solution  in 
the  strength  of  one  drachm  of  each  to  the  ounce  of  alcohol, 
or  the  s()lvent  may  be  tincture  of  iodine,  if  the  stimulating 
effect  of  the  iodine  seems  indicated.  The  other  drugs  men- 
tioned should  be  used  in  the  same  relative  proportions.  A 
third  local  stimulant  of  considerable  value  is  a  mixture  of  the 
oil  of  eucalvjUus  and  pine-needle  oil  in  equal  proportions.  Oil 
of  cloves  mav  be  u^ed  in  strength  of  half  a  drachm  to  the 
ounce  of  alcohol.  When  iodine  is  used,  the  officinal  tincture 
is  the  preparation  best  suited  for  the  purpose.  Ether  and 
chloroform  should  be  used  in  exxeedingly  small  quantities,  as 
they  are  extremely  irritating,  and  their  use  is  attended  by 
considerable  discomfort. 


312     TUBAL  CONGESTION,  OR  TUBAL  CATARRH. 

The  advantages  of  inflating  first  with  air  and  subsequently 
with  a  medicated  vapor,  instead  of  using  the  medicated  air  from 
the  first,  lie  in  the  fact  that  by  this  means  very  little  of  the  medi- 
cated air  is  brought  in  contact  with  the  mucous  membrane  of 
the  nose  and  naso-pharynx,  and  local  irritation  here  is  reduced 
to  a  minimum.  When  medicated  vapors  are  used  the  catheter 
is  alwavs  tlie  instrument  to  be  employed  for  their  introduc- 
tion if  this  is  possible.  Occasionally,  however,  we  may  be 
obliired  to  resort  to  the  Politzer  method  of  inflation  ;  but  if 
possible  this  should  be  avoided. 

Under  prophvlactic  measures  must  be  included  attention 
to  the  mucous  membrane  lining  the  nasal  passages  and  the 
pharvngeal  space.  Inquirv  into  tiie  history  of  these  cases 
shows  that  the  patients  arc  subject  to  frccpicnt  "colds  in  the 
head  or  throat."  If  anv  departure  from  the  normal  condi- 
tion is  present  in  these  regicjns  it  should  be  dealt  with  radi- 
cally. The  removal  of  enlarged  faucial  and  pharyngeal  ton- 
sils, the  reduction  of  a  hvpertrophic  process  within  the  nares, 
either  by  chromic  acid,  the  galvano-cautery,  or  any  other  ap- 
propriate measure,  and  the  actual  removal  of  any  obstructive 
deformity  of  the  septum  or  of  an  extensive  hypertrophy  of 
turbinated  bodies  which  has  failed  to  respond  to  less  radical 
measures,  will  be  necessarv  in  order  to  prevent  repeated  at- 
tacks of  similar  nature.  When  no  deviation  from  the  normal 
standard  exists  aside  from  the  condition  dependent  upon  the 
acute  attack,  the  general  hvgiene  of  the  patient  must  be  in- 
vestigated. The  dailv  use  of  the  cold  bath,  preferably  of  the 
plunge  bath,  is  essential  ;  but  if  this  for  anv  reason  is  contra- 
indicated,  the  cold  sponge  bath  inav  be  substituted.  The  use 
of  all-wool  underwear  and  a  regulation  of  the  habits  of  life 
will  ordinarilv  enable  us  to  prevent  successive  attacks. 

Ordinarilv  the  local  treatment  occupies  the  most  promi- 
nent position  in  the  mind  ot  the  phvsician  :  but  it  can  not  be 
too  stronglv  urged  that  careful  attention  to  the  hvgienic  sur- 
roundings of  the  patient  arc  of  quite  as  much,  and  frequently 
of  more,  importance  than  the  employment  of  the  topical  ap- 
plications. 


en Af^TFR    XVIII. 

TUBO-TYMPANIC    CONGKSTIOX. — ACUTE    TUBO-TV.MrAMTIS. — 
T  U  BO-TV  M  PA  N I C   CAT  A  K  R  H . 

In  this  C()ndition,  in  addition  to  the  chaiii^es  already  men- 
tioned as  occurring  in  the  Eustacliian  tube,  there  is  present  a 
congestion  of  the  mucous  membrane  lining  the  middle  ear, 
dependent  upcKi  the  physical  changes  which  the  tubal  occlu- 
sion causes  rather  than  uj)()n  any  actual  inllanimatory  process 
\yithin  the  tympanum. 

iEtiology. — The  same  conditi(jns  which  produce  a  tubal 
catarrh  niav  cause  the  affection  under  consideration.  The 
exact  condition  which  results  in  any  indiyidual  case  depends 
both  upon  the  actiyity  of  the  exciting  cause  and  uj)on  condi- 
tions within  tiie  tympanum  peculiar  to  the  particular  case. 
It  the  t\  iii|)aiiic  yessels  are  wanting  in  tone  from  some  sys- 
temic condition,  or  have  been  in  a  state  of  engorgement  for  a 
considerable  ])criod  fn^m  local  causes,  the  sudden  occlusion 
of  the  tubal  lumen  will  effect  certain  changes  within  the  mid- 
dle ear  recognizable  ujyon  plnsical  examination,  and  active 
in  the  production  of  certain  subjectiye  sympt<jms.  The  ex- 
citing causes  of  the  attack  are  usually  the  same  as  those  of 
simple  tubal  catarrh,  and  tiuir  reiJCtition  here  is  unnecessary. 

Pathology. — We  may  find  within  the  tympanimi  a  simple 
engorgement  of  the  vessels  supjihing  the  mucous  membrane, 
leading  to  a  general  hyperaemia  of  the  inner  tympanic  wall 
and,  to  a  lesser  extent,  of  the  drum  membrane  itself,  this  being 
most  marked  along  the  course  of  the  vascular  plexus.  This 
congestion  may  result  in  two  conditions — either  one  of  hyper- 
secretion with  the  accumulation  of  mucus  within  the  tym- 
panic cavity,  or  in  a  simple  serous  exudation  due  to  the  tenu- 
ity of  the  vessel  walls.  This  condition  of  the  yessels  is  usu- 
ally of  constitutional  origin  and  is  not  uncommon  in  those 
affected  with  a  gouty  diathesis  or  with  chronic  cardiac,  he- 
patic, or  renal  disease.     In  the  membrana  tympani  this  ve- 

(313) 


314 


TUBO-TYMPANIC   CONGESTION. 


nous  congestion  is  evidenced  by  an  increased  amount  of  blood 
within  the  veins.  As  the  vascular  network  is  most  rich  in 
the  upper  and  posterior  segment  close  to  the  perphery  and 
along  the  manubrium  mallei,  these  localities  show,  upon  in- 
spection, deviations  from  the  normal  color.  It  is  true  that 
stasis  is  the  first  stage  of  anv  inflammation,  but  the  disease 
under  consideration  does  not  usually  progress  further  than 
this  first  stage.  The  reduplications  of  mucous  membrane  in 
the  upper  part  of  the  cavitv  may  also  be  involved,  the  effused 
serum  draining  into  the  atrium  or  bulging  the  upper  part  of 
the  membrane. 

Symptomatology. — The  symptoms  already  enumerated 
under  tubal  catarrh  undergo  slight  modifications  when  the 
cavity  of  the  middle  ear  is  involved.  Instead  of  the  "  stuffy  " 
feeling  so  characteristic  of  Eustachian  occlusion,  these  pa- 
tients frequently  complain  of  distinct  pain  in  the  ears,  while 
the  feeling  of  heaviness  and  numbness  about  the  head  is  less 
marked.  Pain  is  particularly  well  marked  when  the  vault  of 
the  cavity  is  involved.  The  impairment  of  hearing  is  usuallv 
not  as  sudden,  nor  is  it  as  pronounced  as  in  simple  occlusion 
of  the  tube.  This  mav  j^crhaps  be  explained  upon  the  theory 
that  the  slight  swelling  of  the  membrana  tvmj^ani  renders  its 
displacement  bv  atmospheric  pressure  less  easv,  and  conse- 
quently the  ossicles  are  not  crfiwded  together  as  firmlv  as 
when  no  obstacle  is  offered  to  the  displacement  of  the  drum 
membrane.  Tinnitus  is  present,  and  mav  be  distressing;  it 
is  prone  to  be  inllucnced  bv  the  j)osition  of  the  patient,  and 
is  most  complained  of  when  the  horizontal  position  is  as- 
sumed, as  this  posture  increases  the  vascular  engorgement. 
When  there  is  fluid  within  the  middle  ear  the  sufferer  fre- 
quently complains  of  great  variations  in  hearing  according  to 
the  position  of  the  head.  When  sitting  quietly  he  mav  be 
conscious  of  a  slight  impairment,  but  if  the  head  is  suddenly 
bent  backward  this  impairment  becomes  marked,  disappear- 
ing again  when  the  erect  position  is  resumed.  The  reason  is 
that  the  effused  fluid  is  capable  of  a  certain  amount  of  motion 
within  the  middle  ear,  and  when  the  head  is  bent  backward 
flows  to  the  postero-inferior  part  of  the  cavitv,  covering  the 
round  and  oval  windows  and  interposing  an  obstacle  to  the 
entrance  of  sound  waves. 

Another  quite  characteristic  svmptom  is  the  occurrence 
of  a  bubbling  or  snapping  sound  when  the  patient  blows  the 


SYMPTOM  ATOLOGY— DIAGNOSIS. 


315 


nose  forcibly,  or  sometimes  during  the  act  of  deglutition. 
During  the  performance  of  these  acts  the  tubal  obstruction 
momentarily  becomes  less  complete,  and  the  current  of  air 
entering  the  tympanum  passes  through  the  fluid  and  gives 
rise  to  the  sound. 

Autophony  is  also  frequently  complained  of.  while  sub- 
jective noises  may  vary  considerably  according  to  the  posi- 
tion of  the  head,  being  usually  more  severe  in  the  recumbent 
position.  A  condition  of  the  hyperresthesia  of  the  auditorv 
nerve  may  occur  in  these  cases,  causing  certain  sounds  to  be 
painful.  The  sounds  producing  a  painful  impression  are 
high-pitched,  but  ordinarily  not  those  of  the  highest  pitch, 
since  the  occlusion  of  the  niche  of  the  round  window  by  the 
fluid  lowers  the  upper  tone  limit  of  sound  perception  con- 
siderably. 

When  the  ear  has  been  inflated  bv  the  i)atient  himself, 
either  accidentally  or  by  design,  the  liearing  immediately  im- 
proves to  a  surprising  degree,  while  the  retrograde  change 
ma\-  be  (.(iiiallv  sudden  after  the  act  of  deglutition. 

Diagnosis. — A.  Pliysiml  lixamination. — The  inspection  of 
the  parts  bv  means  of  reflected  light  will  reveal  appearances 
which  varv  considerablv  in  the  different  cases  according  to 
the  actual  conditions  present.  The  distinctive  feature,  as  con- 
trasted with  a  simple  tubal  stenosis,  lies  in  the  fact  that  the 
drum  membrane  or  the  internal  tvmpanic  wall  shows  evi- 
dences of  circulatorv  changes,  which  are  absent  when  the  tube 
alone  is  affected.  The  position  of  the  drum  membrane  is 
usually  that  of  moderate  retraction,  the  extent  of  this  not  be- 
ing as  great  as  when  the  tube  alone  is  affected.  The  mem- 
brana  tvmpani  varies  sHghtlv  from  the  normal  color  ;  instead 
of  being  pearly  white,  it  is  changed  to  either  a  dull  white 
throughout,  or  it  is  of  a  light  pinkish-white  tinge.  At  the 
periphery  and  along  the  handle  of  the  malleus  the  change  of 
color  is  decidedly  more  marked  and  is  of  a  tlull-reddish  hue. 
These  changes  in  color  along  the  manubrium  and  at  the  pe- 
ripherv  do  not  indicate  a  true  inflammatory  condition,  but  a 
venous  congestion  simplv.  with  a  consequent  prominence  of 
the  veins  forming  the  manubrial  and  peripheral  plexus.  This 
dull-reddish  color  is  sometimes  very  prominent  above  the 
short  process  from  the  congestion  within  the  tvmpanic  vault 
and  is  indicative  of  the  possibility  of  the  process,  progressing 
to  suppuration.     The  pinkish  tinge  of  the  entire  membrane 


3i6-  TUBO-TYMPANIC   CONGESTION. 

whicli  we  sometimes  observe  is  due  not  to  changes  in  the 
membrana  tympani  itself,  but  to  congestion  of  the  internal 
tympanic  wall.  The  rays  of  light  pass  through  the  mem- 
brana tympani  and  illuminate  the  internal  wall  of  the  middle 
ear,  which  is  in  these  cases  considerably  reddened.  This  col- 
ored background  gives  to  the  membrana  tympani  the  pink- 
ish tinge  described,  but  the  change  in  color  depends  upon 
congestion  within  the  cavity  rather  than  upon  any  changes 
within  the  membrana  tvmpani  itself  aside  from  those  alreadv 
mentioned  as  occurring  in  the  venous  plexus  of  the  mem- 
brane. 

The  malleus  handle  appears  foreshortened  according  to 
the  degree  of  collapse,  but  seldom  to  the  extent  seen  in  sim- 
ple Eustachian  occlusion  ;  the  antcri(jr  and  posterior  folds 
are  more  prominent  than  normal ;  from  stasis  the  membrane 
may  appear  thicker  than  normal,  and  may  partially  lose  its 
lustre.  On  account  of  the  displacement,  the  light  reflex  is 
changed  both  in  position  and  shape,  and  may  be  multiple. 
These  changes  are  recognized  ordinarily  when  no  effusion  has 
taken  place  within  the  tympanic  cavity.  If,  owing  to  the 
abnormal  fullness  of  the  vessels,  a  certain  amount  of  transu- 
dation has  taken  place  within  the  tympanum,  the  degree  of 
depression  is  not  apt  to  be  as  marked.  Instead  of  this,  a  close 
inspection  will  reveal  the  membrana  tympani,  presenting  in 
its  inferior  segment  a  slightlv  yellowish  color,  the  lustre  of 
the  membrane  being  diminished,  while  the  density  is  increased. 
This  dull  look  is  wanting  in  the  upper  part  of  the  membrane, 
the  illuminating  rays  penetrating  it  and  revealing  more  or 
less  distinctly  the  condition  of  the  inner  tymj)anic  wall  ;  and 
if  the  membrana  tvmj^ani  is  thin,  frecpientlv  enabling  the 
observer  to  recognize  the  long  process  of  the  incus  on  the 
posterior  crus  of  the  stapes  (Fig.  95).  The  appearance  is  due 
to  a  collection  of  fluid  in  the  lower  part  of  the  tvmj)anic  cav- 
ity, the  result  of  serous  transudation.  Not  infrequently  we 
observe  the  line  of  demarcation  between  the  upper  and  lower 
areas  as  sharp  and  distinct,  appearing  as  a  fine  line  which 
traverses  the  membrana  tympani  transversely  (see  colored 
plates).  This  line  marks  the  level  of  the  fluid  in  the  tympanic 
cavity,  and  may  be  mistaken  for  a  hair  stretching  across  the 
surface  of  the  drum  membrane.  By  tilting  the  head  of  the 
patient  forward  or  backward,  it  is  often  possible  to  observe 
changes  in  the  direction  of  the  fluid  line.     If  the  patient  prac- 


DIAGNOSIS— FUNCTIONAL    EXAMINATION.  31; 

tices  auto-inflation,  the  current  of  air  upon  cntcrin*;^  the  tym- 
panic cavity  will  bubble  up  through  the  contained  fluid,  and 
upon  inspection  these  bubbles  are  visible  (Fig.  96)  ;  thev 
change  their  position  when  the  patient  swallows  or  forces 
more  air  into  the  tympanic  cavity.  Naturally  their  presence 
is  an  unquestionable  evidence  of  fluid.  In  cases  where  the 
drum  membrane  has  been  thickened  from  preceding  inflam- 


Fig.  95. — Moderate  relraciion  of  mem-  Tig.   96. — Posterior    segment    of    mem- 

brana  tyiiii)aiii.      Incudo-stapediai  .nr-  brana  tympani  liulgcd  by  fluid  in  the 

ticulalion    visible   in    upper   poj.terior  tympanum.    Hubbies  of  air  in  the  iluid 

quadrant.  are  vi.>ible  througli  tiie  membrane. 

maticju  it  mav  be  so  dense  as  to  prevent  the  recogiiilion  of 
these  air  bubbles  upon  ocular  inspection,  in  such  instances 
several  brigiit  points  of  light  are  often  seen  upon  the  surface 
of  the  membrane  below  the  level  of  the  fluid.  These  multi- 
ple reflexes  are  indicative  of  the  j)resence  of  fluid,  althougli 
thev  must  not  be  relied  u]>on  as  absolutelv  characteristic  of 
this  condition.  Inflation  with  the  catheter  or  bv  I'olitzer's 
method  will  reveal,  through  the  diagnosis  lube,  the  character- 
istic bid^bling  as  soon  as  the  air  enters  the  middle  car.  When 
serum  alone  is  present  the  rales  produced  by  the  bursting  of 
the  bubbles  will  be  sharp  and  high-pitched  ;  when  a  certain 
amount  of  mucus  is  mixed  with  the  serum,  the  sound  will  be 
of  lower  pitch  and  of  less  intensity  and  the  explosive  sounds 
will  follow  each  other  at  less  frequent  intervals.  The  absence 
of  rales  upon  auscultation  can  not  be  taken  as  a  positive  evi- 
dence that  no  fluid  is  present  in  the  middle  ear,  A  small 
amount  of  efTusion  may  lie  entirely  out  of  the  air  current  and 
give  no  sign  of  its  presence.  Again,  the  fluid  may  be  incap- 
sulated  in  a  fold  of  the  mucous  membrane,  and  thus  be  unaf- 
fected bv  the  operation  of  inflation. 

B.  Functional  Examination. —  Upon  examining  the  patient 
with  reference  to  the  power  of  audition  we  shall  find  dimin- 
ished air  conduction,  both  for  sharp  sounds — such  as  the 
watch  and  acoumeter — and  for  the  conversational  voice  and 
whispered  speech,  the  defect  for  the  vocal  sounds  being 
relatively  more  marked  than  for  isolated  sharp  sounds.     The 


3i8  TUBO-TYMFANIC    CONGESTION. 

tuning  fork  will  show  an  elevation  of  the  lower  tone  limit, 
while  the  Gallon  whistle  indicates  a  reduction  of  the  upper 
tone  limit.  This  latter  will  be  more  marked  when  fluid  is 
present  and  occupies  such  a  position  as  to  cover  the  round 
and  oval  windows.  The  vibrating  tuning  fork,  placed  upon 
the  forehead,  is  usuallv  lateralized  to  the  more  affected  side  in 
cases  of  bilateral  disease,  or  toward  the  affected  side  when 
only  one  ear  is  involved.  Absolute  bone  conduction  for  a 
fork  of  two  hundred  and  fifty-six  or  five  hundred  and  twelve 
double  vibrations  per  second  is  usually  increased,  although 
sometimes  it  mav  be  slightly  less  than  normal.  While  this 
latter  condition  indicates  the  involvement  of  the  perceptive 
apparatus,  the  labvrinthine  lesion  depends  upon  the  process 
within  the  middle  car,  and  will  disappear  when  the  tvmpanic 
condition  becomes  normal.  The  presence  of  fluid  in  the  mid- 
dle ear  mav  modify  the  results  of  the  functional  tests,  and 
render  an  exact  diagnosis  of  the  condition  of  the  perceptive 
apparatus  impossible  until  it  has  been  removed  by  therapeu- 
tic or  surgical  measures  and  the  conducting  mechanism  has 
been  restored  as  nearly  as  possible  to  its  normal  condition. 

Prognosis. —  In  many  of  these  cases,  especiallv  in  children, 
the  parts  return  to  a  completely  normal  condition  without 
treatment.  In  adults,  while  spontaneous  recovery  occurs  in 
a  certain  proportion  of  instances,  it  is  probable  that  the  func- 
tion of  the  organ  is  not  completely  restored.  Aside  from 
spontaneous  resolution,  we  mav  have  developed,  as  a  result 
of  this  process,  a  chronic  otitis  media,  the  persistent  conges- 
tion of  the  parts  ultimate! v  resulting  in  an  inflammatorv  pro- 
cess of  the  chronic  tvpe.  This  mav  result  either  in  an  hvper- 
trophy  of  the  mucous  membrane  lining  the  cavitv,  the  redu- 
plications increasing  in  number  and  in  densitv,  or  occasionallv 
we  have  developed  a  true  hyperplastic  inflammation,  in  which 
the  connective-tissue  framework  of  the  lining  membrane  of 
the  middle  ear  becomes  firm,  the  interhbrillarv  substance  be- 
ing absorbed,  and  a  sclerotic  condition  is  the  result.  This 
process  is  usually  more  pronounced  in  the  region  of  the  oval 
and  round  windows  than  elsewhere.  The  membrane  of  the 
Eustachian  tube  mav  undergo  similar  changes.  When  the 
hvpertrophic  changes  occur  within  the  tympanum  the  Eusta- 
chian tube  is  also  affected,  its  calibre  being  so  narrowed  that 
ventilation  of  the  tympanum  is  interfered  with.  In  the  hyper- 
plastic or  sclerotic  inflammation  the  result  is  to  increase  its 


TREATMENT— INFLATION  — INCISION. 


319 


calibre  rather  than  to  diniinish  it.  In  those  cases  where  the 
circulatory  system  is  impaired  from  diathetic  causes,  the  effu- 
sion in  the  tympanic  cavity  may  increase  in  amount  when  the 
mucous  membrane  of  the  upper  air  passages  is  congested  as 
the  result  of  exposure  to  cold  or  of  some  disturbance  of  the 
prima;  via?,  diminishing  in  quantitv  or  disappearing  when  the 
patient  is  in  a  fairlv  normal  ccmdition. 

Treatment. — In  the  acute  stage  the  measures  alreadv  men- 
tioned under  the  treatment  of  tubal  catarrh  are  to  be  adopted. 
Proper  attention  to  clothing  and  hygienic  surroundings  and 
the  treatment  of  the  upper  air  passages,  surgicallv  or  other- 
wise, is  of  the  greatest  importance  in  j)revenling  recurrent 
attacks. 

in  addition  to  this  we  have  to  deal  with  the  congestion 
within  the  tympanum  itself,  and  when  effusion  is  present  our 
treatment  must  be  of  such  character  as  to  produce  either 
its  absorption  or  its  exit  by  mechanical  means.  For  the 
relief  of  the  venous  engorgement  local  bloodletting  stands 
pre-eminent.  The  abstraction  of  from  two  to  four  ounces  of 
blood  from  the  region  immediately  in  front  of  the  tragus  is 
frequently  followed  by  a  complete  cessation  of  the  unpleasant 
svmptoms  and  restoration  of  function.  When  seen  earlv,  this 
method  may  prevent  the  effusion  (jf  lluiti  into  the  middle  ear. 
Next  we  should  try  to  prevent  this  transudation  by  restoring 
the  intratvmpanic  pressure  as  nearly  as  possible  to  its  n(jrmal 
standard.  This  is  to  be  effected  by  inllation  of  the  middle 
ear.  either  by  the  Politzer  method  or  by  the  use  of  the  Eusta- 
chian catheter.  Authorities  vary  considerably  as  to  the  pro- 
[)riety  (jf  using  the  air  douche  in  acute  congestion  of  the  tym- 
panum. T(^  my  mind,  there  is  no  question  but  that  iiillation 
is  beneficial  in  a  very  large  proportion  of  these  cases,  and  fre- 
quently shortens  the  duration  of  the  disease,  preventing  tran- 
sudation of  seruin  bv  supporting  the  intratympanic  vessels. 
The  relief  to  the  subjective  symptoms  is  also  very  marked, 
and  in  no  instance  have  I  seen  the  condition  aggravated  by 
the  operation,  even  when  relief  did  not  follow.  After  the 
effusion  of  serum  has  taken  place,  local  bloodletting  is  ordi- 
narily useless  unless  actual  pain  is  present,  and  we  have  rea- 
son to  fear  that  the  process  may  become  inflammatory. 

After  effusion  has  taken  place  our  efforts  should  be  di- 
rected toward  its  removal.  Two  ways  are  available:  either 
evacuation  by  incision  through  the  drum  membrane,  or  re- 


320  TUBO-TYMPANIC   CONGESTION. 

moval  through  the  Eustachian  tube.  The  objection  to  early 
incision  of  the  membrana  tympani  is  the  supposed  tendency 
to  recurrence  when  the  fluid  is  evacuated  in  this  manner. 
Unless  the  transudation  is  considerable  in  amount  and  causes 
much  discomfort,  it  is  well  to  attempt  its  absorption, -reserv- 
ing incision  of  the  drum  membrane  for  persistent  cases  only. 
The  prime  factor  influencing  the  absorption  of  the  fluid  is  a 
patulous  condition  of  the  Eustachian  tube,  thus  relieying  the 
venous  turgcscence  and  permitting  the  passage  of  the  effusion 
into  the  lymphatics.  The  restoration  of  the  tube  to  a  patulous 
condition  is  effected  by  the  use  of  the  catheter,  the.  bougie, 
the  application  of  astringents  to  the  orihce  of  the  tube,  or  in- 
flation with  medicated  vapors.  These  measures  have  been  de- 
tailed under  tubal  catarrh.  When  the  condition  has  existed 
for  a  considerable  time  the  mucous  membrane  of  the  middle 
ear  may  not  readily  take  up  the  fluid.  Here  inflation  with  any 
medicated  vapor  which  will  stimulate  the  lining  membrane 
may  accomplish  the  desired  object.  For  this  purpose  we  may 
use  menthol  or  camphor  in  the  proportion  of  one  drachm  to 
an  ounce  of  alcohol,  the  vapor  of  the  oil  of  eucalyptus  in  full 
strength,  or  even  alcohol  vapor  alone.  It  is  best,  when  the 
fluid  is  not  too  viscid,  to  evacuate  a  certain  amount  of  it 
through  the  Eustachian  tube  by  means  of  the  air  douche.  To 
do  this  the  head  should  be  inclined  forward  and  toward  the 
unaffected  side  during  the  performance  of  the  operation,  and 
occasional  attempts  at  deglutition  should  be  made,  as  this  act 
renders  the  tube  more  patulous  and  permits  the  fluid  to  be 
displaced  more  easily.  An  effusion  of  this  character  should 
yield  to  treatment  in  not  less  than  fourteen  days,  the  air  douche 
being  administered  at  first  daily,  and,  as  the  condition  im- 
proves, at  longer  intervals.  If  a  decided  impression  has  not 
been  made  upon  the  fluid  at  the  end  of  this  time  it  is  unwise 
to  delay  longer,  and  the  membrana  tvmpani  should  be  incised. 
The  same  plan  should  be  adopted  even  at  an  earlier  period  if 
the  patient  can  not  be  kept  under  observation  sutihciently  long 
to  insure  a  complete  restoration  by  the  milder  measures  al- 
ready indicated.  Considerable  difference  of  opinion  exists  as 
to  the  precise  location  and  the  extent  of  incision  through  the 
drum  membrane.  To  m}'  mind  the  question  should  be  de- 
cided on  general  surgical  principles.  The  object  sought  is 
perfect  drainage  and  a  rapid  and  perfect  restoration  of  the 
parts  to  their  normal  condition.     These  ends  can  be  attained 


TREATMENT  — INTERNAL   MEDICATION. 


321 


only  bv  a  free  and  extensive  incision  which  will  evacuate 
all  the  fluid  and  leave  the  parts  in  a  condition  favorable  to 
immediate  union  throughout  the  entire  line  of  section.  In 
order  that  the  drainage  may  be  perfect,  the  lowest  point  of  the 
opening  must  lie  near  the  inferior  pole  of  the  drum  membrane. 
Since  the  upper  and  posterior  part  of  the  cavitv  is  the  most 
capacious,  an  effusion  sufficient  in  amoimt  to  demand  evacua- 
tion usually  causes  a  bulging  of  the  drum  membrane  in  this 
locality.  1  prefer,  therefore,  to  insert  an  exceedinglv  sharp 
but  delicate  knife  close  t(j  the  periphcrv  of  the  mcmbrana  at 
a  point  opposite  the  short  process;  the  knife  is  then  carried 
downward  close  to  the  periphery  to  the  lowest  point  of  attach- 
ment of  the  membrana  tvmpani.  The  section  lies  entirelv 
within  the  clear  membrane,  and  should  not  wound  the  carti- 
laginous ring.  When  eonsiderablc  congestion  is  present  it  is 
advisable  to  secure  local  depletion  bv  carrying  the  knife  suffi- 
ciently inward  to  make  it  im[)inge  upf)n  the  internal  tvmpanic 
wall  so  as  to  divide  the  soft  parts  which  cover  it,  throughout 
the  entire  extent  of  the  incision  through  the  drum  membrane. 
If  the  parts  above  the  short  process  arc  intensely  congested 
the  incision  is  to  be  extended  ujnvard  so  as  to  enter  the  vault 
and  deplete  the  engorged 
tissues.  In  these  cases  it 
is  usual  to  incise  from  be- 
low u|)ward  ( Fig.  97).  A 
few  vigorous  efforts  at  in- 
flation bv  means  of  the 
Politzer  method  clears  the 
cavitv  complctelv  of  fluid, 
the  divided  parts  fall  read- 
ily into  place,  approxi- 
mation being  practically 
•perfect,  and  it  is  not  un- 
usual to  find  complete 
union  at  the  end  of  thirtv- 
six  hours.  The  only  pos- 
sible untoward  result  fol- 
lowing this  procedure  is  accidental  infection  at  the  time  of 
the  operation.  To  avoid  this  the  canal  should  be  first  syringed 
with  a  solution  of  bichloride  of  mercury  (i  to  8,000),  while 
the  instruments  employed  should  be  sterilized  by  boiling. 
After  the  fluid  has  been  evacuated  the  canal  should  be  closed 
22 


Fio.  97. — Method  of  inciting  membrana  tvm- 
pani to  evacuate  fluid  in  the  atrium  (natural 
size). 


322  TUBO-TYMPANIC   CONGESTION. 

by  a  plug  of  aseptic  cotton  and  the  patient  should  on  no  con- 
dition interfere  with  it.  Carried  out  in  this  manner,  there 
is  absolutely  no  danger  in  adopting  this  kind  of  treatment  for 
an  effusion  of  any  kind  within  the  tympanic  cavity. 

Nothing:  has  been  said  concerninij  the  administration  of  in- 
ternal  remedies.  I  have  little  faith  in  the  beneficial  action  of 
any  drug  for  the  correction  of  the  condition  under  considera- 
tion. As  a  prophylactic  measure  it  is  well,  upon  the  disap- 
pearance of  the  attack  to  guard  against  recurrence  by  the 
exhibition  of  drugs  supposed  to  be  particularly  efficient  in 
overcoming  a  lymphatic  diathesis.  This  is  especially  true  in 
the  case  of  children.  The  administration  of  the  iodide  of  iron 
in  doses  of  four  to  eight  grains  three  times  daily,  together  with 
hypophosphites,  will  do  much  in  the  direction  of  causing  a 
spontaneous  disappearance  of  the  deposits  of  lymphatic  tissue 
in  the  naso-p)harynx  and  pharynx.  Often  after  surgical  inter- 
ference, it  is  well  to  employ  these  remedial  agents  for  a  period 
of  a  month  or  six  weeks  to  insure  the  permanency  of  the  re- 
sult. Where  the  condition  depends  upon  a  disturbance  of  the 
vascular  apparatus,  as  in  artcrio-caj)illary  sclerosis,  or  upon  a 
renal  lesion,  the  proper  treatment  of  the  general  disease  mav 
do  much  to  diminish  the  local  process.  The  application  of 
astringent  remedies  to  the  tympanic  cavitv,  either  through 
the  Eustachian  tube  or  through  an  artificial  opening  in  the 
drum  membrane,  is  not,  I  think,  indicated  in  this  condition, 
since  we  are  dealing  not  with  an  inflammation,  but  with  an 
obstruction  to  the  venous  flow. 


CHAPTER   XIX. 

ACUTE   CATARRHAL   OTITIS    MEDIA. 

This  term  is  applied  to  an  actual  inflammatory  condition 
within  the  middle  ear,  resulting  in  an  increase  in  the  normal 
secretion.  In  this  way  it  differs  from  the  process  just  de- 
scribed. Why  in  one  patient  we  should  have  a  simple  con- 
gestion of  the  tympanic  lining,  and  in  another  an  acute  in- 
flammatory process,  the  factors  of  causation  being-  similar  in 
the  two  cases,  it  is  impossible  to  state.  It  seems  that  the 
difference  must  depend  somewhat  upon  the  power  possessed 
by  the  individual  to  resist  the  invasion  of  pathogenic  bacteria 
and  also  upon  the  virulence  or  degree  of  infection  in  the  in- 
dividual case.  It  is  certain  that  venous  stasis  plays  a  part  in 
the  causation,  as  in  this  condition  any  membrane  is  particu- 
larly susceptible  to  the  absorption  of  bacteria.  The  infection, 
then,  of  an  individual  in  perfect  health  might  result  in  the 
first  stage  of  inflammation  simply  or  an  obstruction  to  the 
venous  flow  with  possible  effusion  of  serum  from  mechanical 
causes  alone.  In  an  individual  less  robust  the  infective  pro- 
cess would  be  carried  one  step  farther,  and  we  should  have, 
following  the  stage  of  congestion,  an  actual  inflanmiatory 
process  developed.  Here  again  comes  the  question  as  to 
why  in  certain  instances  this  inflammatory  j)r()ccss  results  in 
the  formation  of  mucous  secretion,  and  in  others  in  the  forma- 
tion of  pus.  We  have  in  the  structure  of  the  middle  ear  a 
sufficiently  clear  explanation  of  this.  I  think.  Remembering 
that  the  upjier  part  of  the  cavity  contains  a  large  amount  of 
connective  tissue,  we  should  expect  infection  in  this  region 
to  be  followed  by  an  inflammation  of  the  cellular  type,  while 
infection  of  the  lower  portion  of  the  cavitv  would  result  in 
a  simple  catarrhal  inflammation  of  the  lining  mucous  mem- 
brane. Clinical  experience  bears  out  this  theory.  It  is  this 
last-named  process  that  occupies  our  attention  at  present. 

^Etiology. — An  acute  catarrhal  otitis  may  complicate  mea- 
sles or  a  cold  in  the  head,  or  may  be  caused  by  the  introduction 

(3»3) 


324  ACUTE    CATARRHAL    OTITIS    MEDIA. 

of  fluids  into  the  middle  ear  through  the  Eustachian  tube 
while  bathing,  or  through  the  use  of  the  nasal  douche.  Vio- 
lent efforts  at  clearing  the  nostrils  may  occasionally  cause  the 
affection  in  the  same  manner.  Any  abnormal  condition  of 
the  upper  air  passages,  particularly  the  presence  of  an  en- 
larged pharyngeal  tonsil  predisposes  to  this  disease.  Ex- 
posure to  cold  or  wet  may  bring  on  an  attack  without  any 
other  symptoms  referable  to  the  upper  air  tract  being  pres- 
ent. Traumatic  rupture  of  the  membrana  tympani  may  lead 
to  an  infection  of  the  atrium  and  a  simple  inflammation  of  its 
lining  membrane,  although  in  most  of  these  instances  the  in- 
flammation is  purulent  in  character. 

Pathology. — The  pathological  changes  have  been  de- 
scribed in  what  has  already  gone  before.  The  inflammation 
is  confined  to  the  superficial  layer  of  the  lining  membrane  of 
the  tympanum,  the  basement  membrane  escaping.  Most  fre- 
quently only  the  lower  part  of  the  tympanic  cavity  is  in- 
volved. The  reduplications  lying  within  the  vault  are  con- 
gested and  swollen,  but  the  process  does  not  go  farther  than 
this.  As  the  result  of  the  inflammation  the  action  of  the  mu- 
cous glands  is  stimulated,  and  their  secretion,  mixed  with  the 
transuded  serum,  fills  the  tympanic  cavity  with  a  turbid  fluid, 
rather  thick  in  consistence  and  containing  much  mucin  and 
holding  in  suspension  desquamated  epithelial  cells.  The 
changes  involve  the  mucous  layer  of  the  membrana  tympani. 
which  becomes  swollen  and,  by  exfoliation  of  its  superficial 
cells,  leaves  the  fibrous  layer  exposed  ;  this  becomes  infil- 
trated also,  and  from  the  pressure  of  the  accumulated  secre- 
tion may  give  way  at  one  point,  permitting  the  pent-up  fluid 
to  flow  into  the  canal.  Spontaneous  perforation  in  these  cases 
probably  depends  as  much  upon  the  increased  pressure  as 
upon  the  actual  inflammatory  process  involving  the  deeper 
layers  of  the  drum  membrane.  The  Eustachian  tube,  while 
partaking  of  these  pathological  changes  to  a  certain  degree, 
is  not  involved  to  the  same  extent  as  in  a  simple  salpingitis, 
the  activity  being  more  directed  toward  the  lining  membrane 
of  the  middle  ear. 

Symptomatology. — The  symptoms  vary  considerably,  ac- 
cording to  the  age  of  the  patient.  For  convenience  we  will 
consider  the  disease  first  as  affecting  adults,  and  later  as  af- 
fecting children. 

A.  In  Adults. — The  early  symptoms  may  be  so  slight  as  to 


PATHOLOGY -SYMPTOMS    IX    ADULTS. 


325 


pass  unnoticed.  They  consist  in  a  feeling  of  fullness  and 
stuffiness  in  the  car,  dependent  upon  the  occlusion  of  the 
Eustachian  canal.  This  sensation  is  soon  followed  bv  juiin  in 
the  ear  referred  to  the  tympanic  cavitv.  and  of  steadily  increas- 
ing severity.  The  degree  of  pain  is  ordinarily  sutliciently  acute 
to  prevent  sleep,  provided  the  attack  occurs  at  night.  The 
pain  is  usually  distinctly  localized,  and  seldom  partakes  of 
the  diffuse  character  found  in  inilammation  of  the  external 
meatus,  while  its  severity  enables  it  to  be  distinjruished  from 
that  due  to  closure  of  the  Eustachian  tube.  The  pain  is  usu- 
ally most  severe  upon  lying  down,  t)wing  to  the  determina- 
tion of  blood  to  the  head  when  this  position  is  assumed.  Sub- 
jective noises  of  high-pitched  character  manifest  themselves 
quite  early,  but  arc  not  complained  of,  on  account  of  the 
severity  of  the  pain.  Inijiairment  of  hearing  is  at  first  slight, 
but  steadily  increases,  and  may  reach  an  exceptionally  high 
degree.  When  the  stage  of  hypersecretion  is  reached  the  pain 
subsides  gradually,  being  replaced  by  a  feeling  of  fullness  or 
heaviness  in  the  side  of  the  head.  Each  act  of  deglutition  is 
painful,  and  the  f)atient  is  conscious  at  these  times  of  the 
entrance  of  air  into  the  tympanum,  its  j)assage  through  the 
fluid  producing  bubbling  sounds,  while  the  movement  which 
it  causes  in  the  intratymj)anic  structures  is  attended  by  lan- 
cinating pain  on  acct)unt  of  the  swollen  condition.  The  body 
temperature  is  seldom  elevated,  but  from  the  severity  of  the 
pain  considerable  prostration  may  follow.  At  any  period 
varying  from  twelve  to  fortv-eight  hours  si)ontaneous  rup- 
ture of  the  nu-miirana  t\-mj>ani  m.iv  take  place,  as  evidenced 
by  the  appearance  of  a  sero-mucous  discharge  from  the  ex- 
ternal auditory  meatus,  and  an  abrupt  cessation  of  the  pain. 
In  many  cases  rupture  does  not  take  place,  and  the  disease, 
having  run  its  course,  leaves  within  the  tymjianic  cavity  a 
collection  of  sero-mucus,  which  then  produces  the  character- 
istic symptoms  of  an  intratympanic  effusion.  If  the  drum 
membrane  is  exceedingly  dense  and  does  not  yield  to  the 
pressure  of  the  fluid,  the  vault  of  the  tymj)anum  may  become 
involved  secondarily,  and  a  purulent  inflammation  supervene. 
In  still  other  instances,  where  no  spontaneous  outlet  is  effect- 
ed, the  lining  membrane  of  the  mastoid  cells  becomes  in- 
volved. The  patient  complains  of  severe  pain  behind  the 
ear,  gradually  spreading  to  the  side  of  the  head.  This  in- 
volvement is  usually   associated    ^vilh   an   elevation  in    body 


326  ACUTE    CATARRHAL   OTITIS    MEDIA. 

temperature  and  an  increase  in  the  severity  of  all  the  symp- 
toms. 

The  discharge  may  cease  spontaneously  at  the  end  of  a 
few  hours  or  days.  It  may  continue  as  a  sero-mucous  dis- 
charge, or  by  exposure  to  the  air  it  may  become  infected,  its 
character  then  changing  to  a  purulent  secretion.  When  this 
occurs,  the  infection  may  spread  to  the  middle  ear,  involving 
the  structures  situated  within  the  vault,  and  may  then  follow 
the  ordinary  course  of  a  chronic  purulent  inflammation  of 
the  middle  ear.  In  other  cases  the  discharge  of  the  fluid  is 
followed  by  a  complete  cessation  of  all  symptoms,  the  open- 
ing of  the  membrana  tympani  closing  spontaneously  and  the 
parts  returning  to  their  normal  condition. 

B.  /;/  Children. — In  very  young  children  the  symptoms 
characteristic  of  an  acute  catarrhal  inflammation  of  the  mid- 
dle ear  may  be  of  so  severe  a  type  as  to  incline  one  to  the 
opinion  that  the  child  is  suffering  from  a  much  graver  dis- 
ease. The  attack  usually  comes  on  at  night.  The  infant  at 
first  tosses  about  in  bed  and  throws  the  arms  upward  over 
the  head,  usually  toward  the  affected  side,  although  this  is 
not  invariable.  After  a  short  period  of  disturbed  sleep  the 
child  wakens  and  gives  evidence  of  intense  suffering.  The 
temperature  is  frequently  exceedingly  high,  and  may  reach 
io6°,  but  usually  varies  from  102°  to  104°.  From  the  very 
fact  that  the  ear  is  usually  the  organ  least  suspected,  we  may 
remain  in  complete  ignorance  of  the  cause  of  this  rise  in  tem- 
perature until,  after  several  hours,  a  sero-mucous  discharge 
appears  in  the  meatus.  This  is  usually  accompanied  by  a 
cessation  of  all  symptoms,  the  child  dropping  off  to  sleep  and 
the  temperature  gradually  falling.  In  certain  cases  the  at- 
tack may  be  ushered  in  by  repeated  convulsions  and  by  vom- 
iting, simulating  very  closely  an  attack  of  meningitis.  With 
the  appearance  of  discharge  in  the  car  pain  usuall}^  ceases, 
and  in  many  cases  the  temperature  becomes  perfectly  nor- 
mal. This  is  not  the  invariable  rule,  however,  even  though 
drainage  is  free.  The  drum  membrane  of  a  child  is  ex- 
ceedingly thin  and  yields  easily  to  the  outward  pressure 
of  the  fluid,  rupturing  before  the  inflammation  within  the 
tympanic  cavity  has  ceased.  An  elevation  of  the  tempera- 
ture, therefore,  may  continue  for  a  few  days  after  perfectly 
free  drainage  is  secured.  When  this  is  the  case  the  tem- 
perature is  apt  to  be  either  remittent  or  intermittent,  the 


SYMPTOMATOLOGY— IN    CHILDREN. 


327 


elevation  in  the  afternoon  reaching  103°  or  104°  in  many 
cases. 

The  character  of  the  discharge  both  in  adults  and  children 
varies  according  to  the  period  of  the  disease.  During  the  first 
few  days  the  fluid  is  large  in  amount,  turbid  from  the  mixture 
of  epithelial  cells,  and  rather  viscid  in  consistence  from  the 
presence  of  mucin.  The  visciditv  of  the  discharge  ofTers  an 
obstruction  to  its  free  exit  through  the  small  opening  in  the 
drum  membrane  and  obstructive  symptoms  mav  occur.  As  a 
rule  the  discharge  is  much  more  profuse  in  children  than  in 
adults  and  contains  a  greater  number  of  epithelial  cells.  When 
the  case  progresses  favorably  the  secretion  graduallv  dimin- 
ishes in  amount,  becomes  thinner  and  more  watery,  and  finally 
disappears  entirely.  If  proper  attention  is  not  paid  to  clean- 
liness the  fluid  may  become  infected  in  the  auditory  canal,  the 
infection  may  spread  to  the  tympanic  cavity,  and  a  purulent 
otitis  media  supervene  from  inoculation  of  the  connective- 
tissue  structures  in  the  tympanic  vault.  This  accident  need 
never  happen  if  proper  attention  is  paid  to  cleanliness.  The 
presence  of  the  secretion  in  the  meatus  tends  to  soften  and 
remove  the  epithelial  matter,  thus  leaving  a  denuded  surface, 
through  which  infection  mav  take  place  and  localized  or  dif- 
fuse otitis  externa  follow. 

After  the  appearance  of  the  discharge  the  constitutional 
symptoms  mav  again  become  severe  if  the  opening  through 
the  drum  membrane  becomes  occluded  either  by  thick  mucus 
or  as  the  result  of  the  reparative  process  ;  especially  is  this 
true  when  a  case  j)rogresses  rapidly  toward  recovery  and  an 
acute  naso-pharvngitis  occurs  as  the  result  of  exposure  to  cold. 
From  this  cause  the  inflammatory  process  within  the  middle 
ear  becomes  augmented  and  a  sudden  increase  in  the  amount 
of  secretion  takes  place.  The  opening  through  the  drum  mem- 
brane is  not  of  sufficient  size  to  permit  of  free  drainage,  and 
the  symptoms  already  described  in  the  earlier  part  of  the  chap- 
ter are  repeated.  A  relapse  of  this  character  is  always  to  be 
feared,  since  there  is  danger  of  secondary  inflammation  of  the 
mastoid  cells.  Occlusion  of  the  opening  in  the  membrana  tvm- 
pani,  even  for  a  short  time,  may  also  result  in  mastoid  involve- 
ment by  any  fresh  access  of  inflammatory  process. 

The  impairment  of  hearing  and  the  subjective  noises  usu- 
ally diminish  after  the  pressure  within  the  tympanum  is  re- 
lieved by  the  passage  of  the  contained  fluid  into  the  auditory 


328  ACUTE    CATARRHAL   OTITIS    MEDIA. 

meatus.  Necrosis  of  the  osseous  tympanic  wall  or  of  the  os- 
sicula  themselves  does  not  take  place  in  simple  catarrhal  otitis, 
although  the  condition  is  frequent  in  the  purulent  variet}'. 
These  sequelae  will  be  considered  under  a  chapter  on  puru- 
lent otitis  media. 

Diagnosis. — A.  Physical  Examination. — An  inspection  of 
the  canal  and  membrana  tj-mpani  in  the  early  stages  will  re- 
veal a  distinctly  hypersemic  condition  of  the  drum  membrane, 
most  marked  in  the  region  of  the  manubrium,  the  redness 
shading  off  gradually  into  the  normal  color  of  the  part.  The 
structures  above  the  short  process — that  is,  in  Shrapnell's 
membrane — may  also  present  a  reddish  color  quite  early  in 
the  disease,  since  the  blood  vessels  of  the  membrana  tym- 
pani  are  richly  distributed  in  this  region  and  venous  conges- 
tion may  be  marked.  The  hypersemia  is  distinguishable  from 
the  vascular  congestion  present  in  tubo-tympanitis  from  the 
fact  that  the  vessels  themselves  do  not  stand  out  prominently, 
but  the  redness  is  diffuse,  merging  gradually  into  the  normal 
pearly  white  color  of  the  membrana  tympani,  while  in  tubo- 
tympanitis the  outline  of  the  vessels  is  distinctly  marked  and 
there  is  a  line  of  demarcation  between  the  hypersemic  areas 
which  are  identical  with  the  normal  vascular  plexus  and  the 
remainder  of  the  membrane.  The  position  of  the  drum  mem- 
brane may  be  normal,  although  quite  frequently  it  is  moder- 
ately depressed  ;  extensive  collapse  of  the  part  upon  the  in- 
ternal tympanic  wall  does  not  occur  as  a  rule.  At  a  later 
period  the  entire  membrana  tympani,  particularly  the  mem- 
brana vibrans,  is  uniformly  reddened ;  the  lustre  is  wanting ; 
the  landmarks  maybe  obscured  on  account  of  oedema;  the 
short  process  of  the  malleus,  however,  is 
seldom  completely  hidden,  even  in  severe 
cases,  if  careful  search  is  made  for  it.  At 
this  period  effusion  has  usually  taken  place, 
the  result  being  to  force  the  drum  membrane 
Fig.  98.~derate  outward  into  the  canal.  The  displacement 
bulging  of  entire     is  usually  most  marked  in  the  upper  and  pos- 

membrana     tym-      ,       •  ,     /t-.  o\        •  i  m  i  i      • 

pani.  tenor   part   (tig.   98);    in    children,   and    in 

adults  where  the  membrana  tympani  is  more 
obliquely  placed  than  usual,  the  membrana  seems  to  be  con- 
tinuous with  the  postero-superior  wall  of  the  meatus,  narrow- 
ing the  fundus  of  the  auditory  canal,  this  region  being  con- 
verted into  a  small  quadrangular  area  of  not  more  than  one 


DIAGNOSIS— PHYSICAL    EXAMINATION. 


329 


quarter  the  normal  size  (Fig.  87).  Such  a  narrowing  is  quite 
as  characteristic  of  bulging  of  the  drum  membrane  as  a  dis- 
tinct globular  mass  filling  the  fundus  of  the  canal.  A  point 
to  be  remembered  in  this  connection  is  that  the  entire  mem- 
brana  tympani  bulges  as  a  whole,  the  change  in  position  not 
being  limited  to  the  membrana  flaccida.  This  is  of  consider- 
able diagnostic  importance  when  we  remember  that  inflam- 
mations of  a  purulent  character  usually  involve  the  upper 
portion  of  the  cavity  first,  and  the  presence  of  fiuid  causes  a 
protrusion  of  the  membrana  tvmpani  above  the  short  process 
of  the  malleus.  More  attention  will  be  paid  to  this  in  a  later 
chapter. 

After  the  discharge  has  made  its  appearance,  an  inspection 
of  the  ear  will  reveal  the  canal  filled  with  sero-mucous  fluid. 
Upon  removing  this,  the  surface  of  the  drum  membrane  will 
be  seen  covered  with  a  dense  white  lustreless  coating.  This 
is  due  to  a  necrosis  of  the  superficial  epithelial  layer,  and  ma5' 
be  easily  removed  by  means  of  the  cotton  pledget,  when  the 
external  surface  of  the  membrana  tvmpani  will  be  seen  to  be 
red  and  swollen.  The  j)oiiit  of  rupture  should  be  searched 
for  carefully,  but  where  the  canal  is  swollen  it  is  sometimes 
difficult  to  hjcatc  it  exactly.  Usually  it  is  found  in  the  in- 
ferior segment,  either  just  bclow^  the  manubrium  or  in  the 
anterior  portion  close  t(i  the  periphery  of  the  drum  mem- 
brane. When  examined  immediately  after  ruj)ture  has  taken 
place,  the  discharge  pours  out  so  rapidly  that  it  is  difficult  to 
determine  exactly  the  location  of  the  opening.  Nor  is  this  of 
importance,  provided  we  ascertain  that  it  is  of  sufficient  size 
to  admit  of  free  drainage.  The  presence  of  a  muco-serous 
discharge  in  the  canal  is  sufficient  evidence  that  perforation 
has  taken  place.  The  use  of  the  Politzer  air  bag  or  of  the 
Eustachian  catheter  will,  when  the  car  is  inflated,  afTord  us  a 
certain  evidence  of  this  from  the  sharp,  high-pitched  perfora- 
tion whistle.  This  sound  is  modified  by  the  passage  of  the 
current  through  the  fluid.  Before  perforation  has  taken  place 
inflation  gives  simply  the  sounds  characteristic  of  fluid  with- 
in the  tympanum. 

In  children  we  are  not  uncommonly  called  upon  for  an 
opinion  immediately  following  an  attack  of  "earache."  From 
the  histor}',  we  learn  that  the  morning  following  an  attack  a 
slight  amount  of  moisture  was  present  upon  the  pillow,  and 
that  the  margin  of  the  orifice  of  the  meatus  was  coated  with 


330  ACUTE    CATARRHAL    OTITIS    MEDIA. 

a  yellowish  incrustation.  At  the  time  of  our  examination  no 
discharge  is  present  in  the  canal,  the  only  symptom  from 
which  the  child  is  suffering  being  an  elevated  temperature. 
Inspection  reveals  congestion  of  the  entire  membrana,  while 
at  one  point  we  are  able  to  make  out  a  localized  haemorrhagic 
deposit.  The  signification  of  this  appearance  is  that  the  at- 
tack was  of  only  slight  severity,  and  that  spontaneous  rupture 
occurred.  The  pressure  was  relieved  by  this  means  of  exit 
to  the  effusion,  and  the  minute  opening  has  already  closed. 
Our  efforts  here  are  confined  to  the  prevention  of  subsequent 
attacks,  as  the  immediate  condition  is  undergoing  sponta- 
neous  resolution. 

B.  Functional  Examination. — Ordinarily  the  pain  is  so  great 
in  these  cases  that  the  functional  examination  is  seldom  made. 
We  shall  find,  however,  that  the  tuning  fork  placed  in  the 
median  line  of  the  skull  will  be  referred  to  the  affected  side  ; 
air  conduction  for  the  lowxr  portion  of  the  scale  will  be  want- 
ing or  much  diminished.  The  upper  tone  limit  may  be  nor- 
mal or  slightly  reduced,  and  absolute  bone  conduction  will  be 
increased.  The  power  of  audition,  both  for  speech  and  for 
sharp  sounds,  will  also  be  much  reduced. 

Prognosis. — These  cases  terminate  favorably,  as  a  rule, 
often  without  treatment.  Purulent  otitis  media  and  involve- 
ment of  the  mastoid  cells  occasionally  occur.  The  latter  con- 
dition may  supervene  whether  perforation  takes  place  or  not. 

If  perforation  does  not  take  place,  the  case  may  fail  to 
undergo  complete  resolution,  and  a  certain  amount  of  fluid 
may  remain  in  the  tympanum,  causing  impaired  hearing  and 
in  a  persistence  of  subjective  noises.  If  the  fluid  is  absorbed, 
the  mucous  membrane  may  fail  to  return  to  its  normal  con- 
dition and  become  the  seat  of  a  chronic  inflammatory  process 
either  of  an  hypertrophic  or  proliferative  type.  From  the 
long-continued  presence  of  fluid  within  the  tympanum  the 
drum  membrane  may  become  relaxed,  and  after  the  fluid  has 
disappeared  this  change  in  tension  may  give  rise  to  subjective 
noise,  and  to  an  impairment  of  audition  from  the  ease  with 
which  it  is  depressed  when  the  atmospheric  pressure  within 
the  middle  ear  is  diminished. 

When  perforation  has  taken  place,  the  opening  may  close 
spontaneously  ;  or  it  maj-  persist,  leaving  the  internal  wall  of  the 
tympanum  exposed  ;  or  the  ligamentous  structures  within  the 
middle  ear  may  undergo  cicatricial  contraction,  displacing  the 


TREATMENT— INSTILLATIONS— INCISION. 


331 


parts  and  interfering  seriously  with  their  function.  This  lat- 
ter condition  usually  results  when  the  inflammation  becomes 
purulent  in  character.  In  a  certain  proportion  of  cases  a 
simple  catarrhal  inflammation  of  the  lower  portion  of  the  tym- 
panum becomes  purulent  from  infection  through  the  Eusta- 
chian canal  before  the  perforation  takes  place.  This  is  par- 
ticularly prone  to  occur  when  the  process  is  active  and  the 
parts  within  the  tympanic  vault  are  excessively  hvperccmic; 
the  disease  then  follows  the  same  course  as  acute  purulent 
otitis. 

Serious  inflammation  of  the  intracranial  structures  prob- 
ably never  occurs  when  the  disease  is  of  a  catarrhal  type.  In 
children,  where  the  tympanic  roof  is  exceedinglv  thin,  it  is 
not  improbable  that  meninges  in  the  immediate  neighbor- 
hood are  congested  ;  but  the  process  stops  here,  and  a  true 
meniiiu^itis  is  not  developed. 

Treatment. — The  first  indication  is  the  relief  of  pain.  The 
patient  should  be  put  to  bed,  a  saline  cathartic  administered, 
and  complete  relief  from  pain  secured  by  the  administration 
of  an  opiate.  In  adults  a  hypodermic  injection  of  ten  to 
twelve  minims  of  Magendie's  solution  is  the  most  convenient 
form  of  administration,  while  in  children  the  camphorated 
tincture  of  opium  is  to  be  preferred.  It  can  not  be  too 
strongly  insisted  upon  that  com[)letc  relief  from  pain  should 
be  secured  for  a  period  of  at  least  five  or  six  hours,  during 
which  time  attempts  should  be  made  to  abort  the  inflamma- 
tion. This  end  is  attained  more  certainly  by  local  blood- 
letting than  by  any  other  measure.  From  two  to  four  ounces 
of  blood  should  be  drawn  by  means  of  the  artificial  leech 
from  immediately  in  front  of  the  tragus,  or  two  natural 
leeches  may  be  applied  in  this  location  if  the  surgeon  prefers 
to  make  use  of  them. 

The  application  of  dry  heat  is  certainly  of  value  in  re- 
lieving pain,  and  does  not  interfere  with  measures  directed 
toward  aborting  the  attack.  The  most  convenient  means  of 
applying  this  is  bv  means  of  the  hot-water  bag  or  Japanese 
pocket  stove.  Moist  heat  is  objectionable,  since  it  favors 
venous  congestion,  softens  the  tissues,  and  hastens  local  ne- 
crosis, rather  aiding  the  development  of  the  process  we  desire 
to  abort.  Theoretically  cold  applications  would  be  of  benefit ; 
but  the  presence  of  any  fluid  of  low  temperature  within  the 
external   auditory   canal    is   painful    under   ordinary  circum- 


332  ACUTE    CATARRHAL    OTISIS    MEDIA. 

Stances,  and  when  the  parts  are  acutely  inflamed  it  is  unbear- 
able. 

It  is  decidedly  unwise  to  instill  any  oily  solutions  into  the 
canal  for  the  relief  of  pain.  This  practice  is  very  common, 
and  only  serves  to  obscure  the  parts  when  an  examination  is 
made,  and  possesses  absolutely  no  therapeutic  value.  A  so- 
lution of  carbolic  acid  in  glycerin,  in  the  proportion  of  one 
to  twenty,  is  sometimes  of  service,  and  there  is  no  objection 
to  its  use.  The  same  may  be  said  of  aqueous  solutions  of 
morphine,  atropine,  and  cocaine.  The  relief  obtained  is  usu- 
ally temporary,  and  we  simply  prolong  the  duration  of  the 
disease  by  their  use. 

Failing  to  abort  the  attack,  and  the  pain  continuing,  we 
should  not  delay  incision  of  the  membrana  tympani.  It  is  of 
great  importance,  I  believe,  to  perform  this  operation  early, 
and  not  to  wait  until  it  is  evident  that  spontaneous  rupture 
will  take  place  unless  the  fluid  is  evacuated  artificially.  The 
local  depletion  secured  by  the  operation  is  of  great  value, 
while  the  relief  to  pain  is  usually  immediate  and  permanent. 
If,  then,  at  the  end  of  twelve  hours,  the  patient  still  com- 
plains of  pain,  the  membrana  tympani  should  be  freely  incised. 
When  distinctly  bulging,  the  centre  of  the  incision  should  be 
over  the  most  prominent  point ;  but  in  the  absence  of  any  par- 
ticular sign  to  guide  us,  the  knife  should  be  entered  close  to 
the  periphery  of  the  membrana  tympani.  just  below  the  pos- 
terior fold,  and  the  membrana  completely  divided  by  a  curved 
incision  downward  to  its  inferior  pole,  the  incision  lying  en- 
tirely within  the  clear  membrane  and  parallel  to  its  line  of 
insertion.  It  is  also  wise  to  incise  at  the  same  time  the  mem- 
brane of  the  internal  tympanic  wall  to  secure  additional  de- 
pletion. This  procedure  is  of  value  even  when  but  a  small 
amount  of  transudation  has  occurred.  The  operator  should 
be  exceedingly  careful  to  use  a  knife  which  will  pass  through 
the  membrane  by  its  own  weight,  under  which  circumstances 
scarcely  any  pain  is  experienced.  Attempts  to  anaesthetize 
the  membrana  tympani  by  a  strong  solution  of  cocaine  scarcely 
diminish  the  pain  instant  upon  the  operation,  although  where 
the  superficial  epithelium  has  been  cast  off  they  may  be  of  a 
certain  amount  of  value. 

Before  the  operation  the  field  should  be  rendered  aseptic 
in  the  manner  already  described  in  the  consideration  of  a 
similar  operation  in  the  chapter  on  tubo-tympanitis.     After 


TREATMENT— IRRIGATION.  33- 

the  membrana  has  been  divided,  irrigation  with  a  warm  anti- 
septic solution  relieves  whatever  pain  may  be  present,  and 
aids  the  divided  vessels  to  return  to  their  normal  calibre.  If 
section  is  performed  early  we  may  cut  short  the  attack,  the 
incision  closing  at  the  end  of  thirty-six  or  forty-eight  hours, 
and  the  symptoms  subsiding  completely.  When  the  oper- 
ation has  been  postponed  until  the  process  is  well  advanced, 
the  discharge  ordinarily  continues  for  a  period  of  two  to  ten 
days,  and  may  be  quite  profuse  at  first.  During  the  period 
of  discharge  which  may  follow  either  spontaneous  rupture  or 
evacuation  by  surgical  interference,  the  canal  must  be  kept 
thoroughly  cleansed.  This  end  is  best  attained  bv  the  fre- 
quent use  of  the  ear  syringe  in  the  hands  of  an  attendant. 
The  cleansing  fluid  may  be  either  water  which  has  been 
boiled  and  allowed  to  co(j1  until  it  can  be  tolerated  bv  the 
patient,  or  a  mild  antiseptic  solution  mav  be  used.  The  fre- 
quency with  which  irrigation  may  be  performed  will  depend 
upon  the  amount  of  discharge.  At  first  the  ear  mav  require 
cleansing  six  times  dailv  ;  the  interval  is  graduallv  j>r(jlonged 
as  the  discharge  becomes  less  viscid  and  diminished  in  cjuan- 
tity.  It  is  important  that  these  cases  should  be  seen  at  first 
daily  by  the  surge<m  himself,  at  which  time  anv  fluid  within 
the  tympanic  cavity  should  be  thoroughly  evacuated  by  the 
use  of  the  air  douche,  the  parts  being  afterward  dried  with 
absorbent  cotton.  It  has  been  my  practice,  where  I  have 
been  able  to  observe  the  case  daily,  to  insufflate  a  small 
amount  of  boric  acid  into  the  canal  after  cleansing,  thus  se- 
curing a  permanently  aseptic  condition  of  the  parts,  and 
guarding  against  carelessness  on  the  part  of  the  attendant, 
which  might  result  in  infection.  Under  no  condition  is  a 
large  amount  of  powder  to  be  introduced  into  the  ear,  and 
unless  the  ear  is  inspected  daily  it  should  be  a  cardinal  rule 
that  no  powders  are  to  be  used.  When  the  discharge  has 
nearly  ceased,  and  is  so  small  in  amount  that  it  does  not  ap- 
pear in  the  external  meatus  when  the  ear  is  left  undisturbed 
for  twenty-four  hours,  more  prompt  recovery  takes  place  if 
fluid  applications  are  discontinued  entirelv,  the  discharge 
being  removed  by  absorbent  cotton,  after  which  a  small 
amount  of  boric  acid  is  dusted  over  the  parts.  This  suffices 
to  preserve  an  aseptic  condition,  while  a  complete  absence  of 
fluid  causes  a  more  speedy  return  to  a  normal  condition. 

In  cases  of  spontaneous  rupture  the  opening  may  be  so 


334 


ACUTE    CATARRHAL    OTITIS    MEDIA. 


small  that  drainage  is  not  perfect.  "When  these  cases  are 
seen  late  in  the  course  of  the  disease,  our  first  efforts  should 
be  directed  toward  enlarging-  the  opening  and  thoroughly 
cleansing  the  tympanic  cavity  by  driving  out  the  contained 
fluid  with  the  air  douche.  If  this  does  not  suffice,  the  tym- 
panum may  be  washed  out  with  a 
saturated  solution  of  boric  acid  by 
means  of  the  middle -ear  syringe 
(shown  in  Fig.  99).  If  examination 
shows  the  lining  mucous  membrane 
to  be  considerably  thickened,  the 
instillation  of  a  few  drops  of  a  two- 
per-cent  solution  of  nitrate  of  silver 
or  a  four-per-cent  solution  of  sul- 
phate of  zinc  suffices  to  correct  the 
condition.  In  many  cases  a  single 
application  is  followed  by  a  com- 
plete cure.  The  medicinal  solutions 
are  instilled  either  w-ith  the  middle- 
ear  syringe  or  a  simple  middle-ear 
pipette  of  glass.  Care  should  be 
taken  when  nitrate  of  silver  is  used 
to  begin  with  a  very  weak  solution, 
since  the  patient  may  possess  a  pe- 
culiar idiosyncrasy  toward  this  drug,  and  the  reaction  fol- 
lowing its  application  ma}'  be  severe.  If,  after  the  first  trial, 
we  find  the  parts  tolerant,  the  strength  may  be  gradually 
increased  until  the  desired  results  are  obtained.  When  the 
pharynx  is  filled  with  hypertrophied  lymphatic  tissue,  we  find 
that  the  case  is  particularly  liable  to  a  relapse  when  the  dis- 
charge has  almost  ceased.  There  is  no  reason  why  the  pres- 
ence of  an  otitis  media  of  this  character  should  influence  us 
to  delay  the  removal  of  the  hypertrophied  lymphatic  tissue 
after  the  acute  aural  symptoms  have  subsided.  Its  removal 
will  be  necessary  to  prevent  subsequent  similar  seizures,  and 
will  certainly  favor  a  rapid  termination  of  the  present  attack. 
After  the  opening  of  the  membrana  tympani  is  closed,  the 
patient  should  be  kept  under  observation  until  the  parts  pre- 
sent a  perfectly  normal  appearance.  A  certain  amount  of  re- 
laxation of  the  drum  membrane  and  of  the  intratA'mpanic  lig- 
aments follows  an  inflammation  of  this  character,  and  may 
result  in  the  formation  of  adhesions  in  the  tj'mpanum  unless 


Fig. 


99.  —  Blake's 
syringe. 


middle-ear 


TREATMENT— IRRIGATION. 


33? 


certain  measures  are  instituted  to  prevent  it.  Inflation  of 
the  middle  ear  should  be  practised  at  first  dailv,  and  subse- 
quently at  longer  intervals,  until  all  traces  of  congestion  dis- 
appear and  the  membrane  retains  its  normal  position. 

In  these  cases,  and  also  in  instances  where  the  membrana 
tympani  remains  intact,  a  certain  amount  of  fluid  may  be  left 
in  the  middle  ear.  The  application  of  stimulating  vapors  to 
the  lining  membrane  of  the  cavity  will  hasten  absorption  of 
this  residual  fluid.  For  this  purpose  nothing  is  better  than 
the  vapor  from  an  alcoholic  solution  of  menthol,  sixty  grains 
to  the  ounce.  Oil  of  eucalyptus,  or  pine-needle  oil  of  the 
strength  of  a  drachm  to  the  ounce,  may  also  be  employed, 
the  vapor  being  conveved  to  the  middle  ear  through  the 
Eustachian  catheter.  The  introduction  of  simple  or  medicated 
steam  into  the  tympanum  has  fallen  somewhat  into  disuse. 
It  possesses  no  advantages  over  dry  vapors,  and  its  use  is  at- 
tended with  a  certain  amount  of  discomfort  to  the  patient 
and  is  tedious  for  the  operator. 

Subjective  noises  mav  persist  for  a  considerable  time  after 
hearing  has  returned  to  a  j)ractically  normal  condition.  The 
question  of  a  secondary  inflammation  of  the  labyrinth  presents 
itself  at  this  j)eriod.  From  observation  of  a  large  number  of 
patients  we  find  that  the  labvrinth  is  seldom  seriously  in- 
volved in  this  disease.  The  subjective  noises  ultimately  dis- 
appear when  the  mucous  membrane  of  the  tympanum  returns 
to  an  absolutely  normal  condition.  The  failure  tjf  this  sylnp- 
tom  to  disappear  need  give  rise  to  no  uneasiness.  When  the 
noises  are  particularlv  distressing,  relief  is  obtained  by  the 
administration  of  dilute  hydrobromic  acid  in  doses  of  thirty 
to  forty-five  minims  two  or  three  times  daily.  The  suscepti- 
bility of  the  receptive  centres  is  blunted,  and  after  the  noises 
have  once  disappeared  they  seldom  recur.  It  is  wise  to  avail 
ourselves  of  the  use  of  the  drug,  since  the  continued  stimula- 
tion of  this  part  of  the  receptive  apparatus  rather  militates 
against  an  early  disappearance  of  the  symptom. 


CHAPTER   XX. 

ACUTE   PURULENT   OTITIS   MEDIA. 

The  presence  of  pus  in  any  locality  depends  upon  a  ne- 
crotic process  involving  the  deeper  tissues  of  the  region. 
In  the  middle  ear  the  upper  portion  of  the  tympanic  cavity, 
presents  an  exceedingly  favorable  site  for  the  development 
of  a  purulent  inflammation,  since  in  this  region  considerable 
connective  tissue  is  present,  forming  the  framework  of  the 
mucous  reduplications  of  the  tympanic  vault,  as  well  as  of  the 
ligamentous  bands  fixing  the  ossicles  to  the  walls  of  the  tym- 
panum and  uniting  them  to  each  other. 

A  purulent  otitis  media  primary  in  character  is  indicative 
of  an  infection  in  this  region,  as  distinguished  from  a  similar 
process  involving  the  lower  portion  of  the  tympanic  cavity. 

^Etiology. — In  order  that  tissue  necrosis  may  take  place, 
the  organism  producing  it  must  possess  a  certain  amount  of 
virulence.  One  of  the  most  common  causes,  therefore,  of 
purulent  otitis  media  is  some  acute  infectious  disease.  The 
affection  most  frequently  followed  by  the  disease  under  con- 
sideration is  scarlatina,  although  it  may  appear  during  the 
course  of  pneumonia,  epidemic  influenza,  variola,  typhus,  or 
cerebro-spinal  meningitis.  It  often  follows  the  introduction 
of  fluid  into  the  middle  ear  through  the  Eustachian  tube. 
The  extension  of  an  external  otitis,  either  diffuse  or  circum- 
scribed, may  set  up  a  purulent  otitis  media,  access  to  the 
middle  ear  being  gained  through  the  Rivinian  segment.  The 
rupture  of  the  drum  membrane,  either  from  any  foreign  body 
introduced  into  the  meatus  or  by  violent  inflation  of  the  tym- 
panum, may  be  followed  by  a  similar  result. 

Occasionally  vegetable  molds  developing  in  the  canal  in- 
volve the  middle  ear  by  continuity.  A  purulent  inflammation 
in  any  other  part  of  the  body  may  infect  the  tympanic  cavity 
secondarily,  although  this  is  an  uncommon  occurrence.  As 
stated    in  the   previous  chapter,  the  disease  may  follow   an 

(336) 


PATHOLOGY. 


337 


acute  catarrhal  otitis  media  by  infection  of  the  exudation 
citlicr  through  the  Eustachian  tube  or  after  it  has  gained  an 
exit  through  the  drum  membrane  and  appeared  in  the  ex- 
ternal meatus. 

Pathology. — The  hrst  stages  of  the  process  consist  in  a 
hyper^emia  of  the  affected  parts.  The  folds  in  the  vault  of 
the  tympanum  become  engorged  with  blood,  increase  in  vol- 
ume, and  (jtten  fill  the  Sj)ace  comj)letelv,  shutting  ofT  all  com- 
munication with  the  atrium.  This  period  of  congestion  is 
tollowed  by  a  tiansudation  of  the  fluid  elements  of  the  blood 
and  a  migration  of  white  blood  cells.  Following  this,  local 
necrosis  takes  place,  the  tissue  breaking  down  with  the  forma- 
tion of  pus.  As  the  result  of  the  local  cedema  the  blood  sup- 
ply of  the  ossicular  chain  is  considerablv  interfered  with, 
and  bony  necrosis  may  occur  quite  early.  This  usually  takes 
])lace  first  in  the  incus,  on  account  of  the  limited  blood  supply 
in  proportion  to  its  size  and  the  fact  that  its  nutrient  vessels 
[Hirsue  such  a  course  as  to  be  subjected  to  pressure  quite 
early  in  the  attack.  The  surrounding  walls  of  the  tympanum 
may  also  become  involved,  although  this  rarely  occurs  early 
in  the  disease.  Occasionally  the  process  may  start  as  an 
acute  osteitis  either  of  some  portion  of  the  ossicular  chain  or 
of  the  bony  walls  of  the  tympanum,  the  soft  jiarts  being  in- 
volved secondarily.  This  condition  is  occasionally  met  with 
in  |)atients  suffering  from  tuberculosis. 

After  the  inflammation  is  fuUv  developed  and  the  parts 
have  become  engorged  with  blood,  transudation  of  the  fluid 
elements  of  the  blood  takes  place,  together  with  migration  of 
the  white  bhx^d-corpuscles  which  pass  out  of  the  vessels  into 
the  surrounding  tissue;  the  fluid  transuded  naturally  gravi- 
tates to  the  lowest  portion  of  the  cavitv.  The  exact  position 
occu{)ied  by  the  fluid  will  dej)end  uj)on  the  particular  forma- 
tion of  the  tympanum  in  any  individual  case;  occasionally  the 
mucous  folds  are  so  developed  that  the  transudation  is  con- 
fined and  does  not  enter  the  general  tympanic  cavity.  It 
will  be  remembered  that  the  long  process  of  the  incus  passes 
downward  from  the  body  of  the  ossicle  into  the  atrium  ;  this 
fact  plays  an  important  part  in  the  cases  under  consideration, 
since,  when  the  tissues  within  the  tympanic  vault  are  much 
swollen,  the  long  process  of  the  incus  forms  a  natural  drain 
along  which  the  fluids  may  pass  into  the  lower  portion  of  the 
tympanic  cavity  from  the  space  above.  We  find  that  where 
23 


338  ACUTE    PURULENT   OTITIS   MEDIA. 

the  inflammatory  products  from  the  vault  collect  in  the  atrium 
and  subsequently  perforate  the  membrana  tympani  this  per- 
foration lies  in  the  upper  and  posterior  quadrant  close  to  the 
tympanic  ring  and  just  below  the  incudo-stapedial  articula- 
tion. The  fact  that  perforations  located  in  this  region  are  per- 
sistent and  that  the  inflammatory  processes  developed  here 
are  specially  painful  is  a  fact  that  has  long  been  noted ;  its 
particular  significance,  however,  has  been  explained  but  lately. 
Sometimes,  owing  to  the  topography  of  the  organ,  the  upper 
part  of  the  cavity  is  completely  divided  from  the  lower  por- 
tion. The  inflammatory  products  in  these  cases  can  not  pass 
alonof  the  descending  arm  of  the  incus  into  the  atrium,  and 
therefore  crowd  the  upper  portion  of  the  membrana  tympani 
outward.  This  bulging  of  the  membrana  flaccida  is  particu- 
larly characteristic,  and  is  sometimes  present  to  such  a  degree 
that  the  distended  portion  sinks  down  over  the  membrana 
vibrans,  partially  or  completely  concealing  it  from  view.  I 
have  seen  one  instance  in  which  the  bulging  was  so  extensive 
that  the  membrana  flaccida  protruded  from  the  meatus  and 
might  easily  have  been  mistaken  for  a  polyp.  Upon  incision 
a  large  amount  of  fluid  was  evacuated,  retraction  took  place, 
and  examination  revealed  the  opening  in  the  superior  quad- 
rant just  above  the  posterior  fold.  It  is  probable  that  those 
cases  of  otitis  media  in  which  the  atrium  seems  to  be  the  pri- 
mary seat  of  purulent  inflammation  are  really  instances  in 
which  the  inflammatory  products  have  passed  from  the  vault 
into  the  atrium  along  the  long  process  of  the  incus,  as  it  is 
hardly  possible  for  a  purulent  inflammation  to  originate  in  a 
cavity  whose  mucous  lining  is  closely  applied  to  the  bony 
walls.  Where  evacuation  does  not  occur,  either  spontaneously 
or  at  the  hand  of  the  surgeon,  the  fluid  may  dissect  the  soft 
tissues  of  the  canal  for  a  certain  distance  along  the  superior 
and  posterior  wall,  since  in  this  region  the  periosteum  of  the 
canal  is  directly  continuous  with  the  membrana  flaccida  and 
is  but  loosely  attached  to  the  bony  margin  of  the  meatus. 
This  gives  rise  to  a  sinking  of  the  postero-superior  wall  of  the 
meatus  and  a  narrowing  of  the  deeper  portion  of  the  canal. 
The  pus  may  burrow  along  the  entire  length  of  the  wall  and 
make  its  appearance  in  the  post-auricular  region  as  a  soft, 
fluctuating  swelling.  This  is  particularly  liable  to  occur  in 
children,  where  the  tissues  are  less  firmly  attached  to  tiie 
parts  beneath,  and  the  membrana  tympani  is  so  superficially 


SYMPTOMATOLOGY 


339 


placed.     Cases  of  this  class  are  particularlv  prone  to  mastoid 
complication. 

Examination  of  a  large  number  of  cases  teaches  us  that  the 
mastoid  is  usually  involved  before  the  soft  parts  covering-  the 
postero-superior  wall  of  the  canal  become  detached  from  the 
underlying  bone.  Hence,  evidence  of  a  collection  of  fluid  in 
this  region  constitutes  an  almost  pathognomonic  sign  of  mas- 
toid iuHammation.  In  children,  where  the  purulent  collection 
has  dissected  off  the  posterior  wall  of  the  canal  and  formed  a 
post-aural  abscess,  the  periosteum  on  the  outer  surface  of  the 
temporal  bone  may  become  detached  unless  the  fluid  is  freelv 
evacuated,  and  infection  of  the  intracranial  structures  mav 
take  place  either  through  the  mastoid  squamous  fissure  which 
remains  open  for  a  considerable  period  after  birth,  or  a  local- 
ized caries  or  necrosis  of  the  squamous  portion  mav  take  place 
on  account  of  interference  of  the  blood  supply,  and  direct  in- 
fection follow.  Several  cases  of  this  character  have  been  re- 
ported, and  it  has  fallen  to  my  lot  to  witness  two* — one  in  a 
child  and  one  in  an  adult.  The  involvement  of  the  cranial  con- 
tents in  this  manner  is  the  exception,  the  infection  usually  tak- 
ing place  cither  through  the  tympanic  roof  or  through  one  of 
the  large  venous  sinuses  in  the  immediate  neighborhood  of  the 
middle  ear.  Either  condition  mav  occur  bv  a  transmission 
of  the  infecting  material  through  the  communicating  venous 
channels,  or  local  caries  mav  take  place  and  a  large  amount 
of  pus  be  brought  in  contact  with  the  surface  of  the  meninges 
or  enter  directly  into  the  blood  current  through  one  of  the 
large  sinuses. 

Symptomatology.  —  The  characteristic  svmptom  of  an 
acute  purulent  otitis  is  sudden  and  excruciating  pain  deep 
within  the  ear.  Attending  this  we  have  a  decided  elevation 
of  temperature,  the  thermometer  registering  from  ioi°  to 
103°,  severe  headache,  constipation,  and  marked  constitu- 
tional depression.  The  hearing  becomes  rapidly  impaired, 
there  is  often  distressing  tinnitus,  and  in  some  cases  vertigo. 
When  the  disease  occurs  in  children  the  symptoms  are  even 
more  marked,  the  attack  being  frequently  ushered  in  with 
general  convulsions.  The  pain  changes  quickly  from  one  I0-. 
calized  within  the  ear  to  a  rather  diffuse  headache  upon  the 
affected  side.    In  severe  cases  even  in  adults  delirium  is  occa- 


Archives  of  Otology,  vol.  xxi,  p.  253. 


340 


ACUTE    PURULENT    OTITIS  MEDIA. 


sionally  present.  High  temperature  in  marked  contrast  to 
the  very  moderate  increase  observed  in  an  acute  catarrhal 
inflammation  indicates  the  more  profound  constitutional  infec- 
tion. The  pain  continues  unabated  unless  relieved  artificially 
until  the  inflammatory  products  are  evacuated.  This  may 
not  occur  for  several  days  if  the  condition  is  not  interfered 
with.  The  occurrence  of  discharge  offers  some  relief  to  the 
pain,  although  it  does  not  entirely  remove  it,  since  the  tissues 
are  so  oedematous  that  the  opening  is  seldom  large  enough 
to  permit  free  drainage.  The  fluid  that  fills  the  auditory 
canal  is  usually  at  first  sero-purulent,  but  quickly  changes  to 
a  distinctly  purulent  character.  Involvement  of  the  mastoid 
cells  may  occur  before  the  appearance  of  discharge  or  at 
a  subsequent  period.  In  either  event  it  is  characterized  by 
increased  pain,  and  an  augmentation  in  the  severity  of  all  of 
the  general  symptoms.  The  location  of  pain  changes  some- 
what and  is  referred  to  the  region  immediately  behind  the 
auricle  rather  than  to  the  ear  itself.  Involvement  of  the  struc- 
tures within  the  cranial  cavity  is  usually  characterized  by 
an  increase  in  the  temperature,  violent  delirium,  convulsive 
movements  followed  by  paral3-sis  or  paresis,  either  upon  the 
corresponding  or  the  opposite  side,  according  to  the  particular 
area  involved.  When  invasion  of  one  of  the  large  sinuses  of 
the  dura  mater  takes  place  either  from  the  middle  ear  it-self 
or  from  the  subsequent  mastoid  involvement,  svmptoms  of 
pyaemic  infection  appear.  These  are  a  sudden  high  tempera- 
ture, frequently  reaching  103°  or  106°,  with  an  equally  sudden 
return  to  normal  or  even  to  subnormal,  profuse  s^^veating,  and 
rigors.  These  changes  in  temperature  are  repeated  at  inter- 
vals varving  from  a  few  hours  to  one  or  two  days. 

Evidences  of  extension  to  the  labvrinth  are  the  sudden 
appearance  of  dizziness,  nausea,  and  either  absolute  deafness 
for  all  notes  or  complete  loss  of  perception  for  certain  portions 
of  the  musical  register,  usually  the  high  notes  of  the  scale. 
Extension  in  this  direction  is  rather  unusual,  a  fact  which 
would  suggest  that  the  vascular  communication  between  the 
middle  ear  and  the  labyrinth  through  the  intervening  bony 
wall  is  not  as  extensive  as  the  investigations  of  Politzer  * 
would  cause  us  to  believe. 

Diagnosis. — A.  Physical  Examination. — Recognition  of  this 

*  Arch,  fiir  Ohrenheilk.,  vol.  xi,  p.  237. 


DIAGNOSIS.  3^, 

condition  in  its  very  early  stages  is  of  the  utmost  importance, 
since  the  disease  is  always  a  severe  one,  being  dangerous  not 
only  to  the  function  of  the  organ,  but  often 'to  life  itself. 
Particular  attention  should  be  given  to  an  inspection  of  those 
parts  lying  above  the  short  process  of  the  malleus  whenever 
severe  pain  in  the  ear  is  complained  of.  It  is  the  rule  that  in 
the  very  early  stage  that  portion  of  the  mcmbrana  tympani 
alone,  lying  above  the  short  process  of  the  malleus,  is  the 
only  part  which  presents  the  slightest  departure  from  the 
normal  appearance.  Here  close  inspection  will  reveal  the 
fact  that  the  membrane  is  distinctlv  congested,  presenting  a 
deep  dull-red  color  characteristic  of  a  high  degree  of  venous 
engorgement  of  the  underlying  structures.  This  hypera^mia 
does  not  extend  below,  and  frequently  not  as  far  as  the  poste- 
rior fold,  and,  if  a  hasty  examination  be  made,  may  entirely 
escape  observation.  It  is  in  this  verv  early  stage  that  promj)t 
measures  may  serve  to  abort  the  attack ;  hence  the  stress 
which  is  laid  upon  the  phvsical  characteristics. 

When  viewed  somewhat  later,  well-marked  engorgement 
of  these  structures  is  seen  to   be  present,  the   membrana  flnc- 
cida    being    pushed    outward    and    somewhat 
downward  (Fig.  lOO).     The  entire  region  is  of 
a  deep-red  color,  the  parts  being  oedematous.        /  ^ 

the  external  surface  moist,  and  the  n(jrmal  lus- 
tre entirely  wanting.  The  tumefaction  mav  be 
so  great  as  to  actually  sink  downward  into  the 
canal  to  the  level  of  the  short  process,  or  mav     f""'-  loo.— Acute 

1  -^        TTTi  II        1  III  '  purulent    otitis 

overhang  it.  W  hen  well  advanced,  the  hyper-  media; bulging 
a;mia  becomes  general,  and  involves  the  entire        ^^    membrana 

,  ...  ,  ,  flaccida. 

tympanic    membrane.       Sometimes    the    short 
[)rocess  may  be  completely  hidden  by  the  (i-denia  of  the  sur- 
rounding parts,  although  this  landmark  can  usuallv  be  found 
if  sought  for  carefully.      The  outline  of  the    manubrium  is 
almost  alwavs  lost. 

In  cases  complicating  scarlatina,  or  anv  disease  where  the 
infection  has  been  sudclen  and  violent,  an  appearance  which 
may  deceive  is  one  in  which  the  membrana  tympani  presents 
a  dead-white  color.  This  is  due  to  a  necrosis  of  the  superfi- 
cial epithelium  covering  it,  the  loss  of  lustre  being  character- 
istic of  the  condition.  This  superficial  layer  is  easily  removed 
by  the  cotton-tipped  probe,  and  reveals  the  red  membrane 
beneath.     Where  fluid  has  drained  into  the  lower  portion  of 


342 


ACUTE    PURULENT    OTITIS    MEDIA. 


the  tympanic  cavity  the  entire  membrana  tympani  may  bulge 
into  the  canal  instead  of  presenting  a  localized  bulging  area 
at  the  upper  part.  The  appearance  then  does  not  differ  from 
that  shown  in  Fig.  98.  The  secretion  may  be  so  confined  by 
the  mucous  folds  within  the  tympanum  as  to  present,  upon 
examination,  several  tumefied  masses  lying  in  the  fundus  of 
the  canal  close  to  the  superior  wall.  These  may  be  two  or 
three  in  number,  according  as  the  fluid  is  confined  in  the  an- 
terior and  posterior  pockets  of  the  membrane,  or  has  entered 
these  and  the  median  space  known  as  the  pocket 
of  Troeltsch  as  well  (Fig.  loi).  Inspection  of 
such  a  case,  where  a  clear  history  can  not  be 
obtained  as  to  the  length  of  time  the  disease 
has  lasted,  is  misleading,  the  bulging  areas 
being  frequently  mistaken  for  masses  of  granu- 
FiG.  loi.— Acute  lation  tissue.  Where  perforation  has  taken 
purulent  otitis     place  spontaneously,  we  most  frequently  find 

media  ;      fluid      ^  ^  -^  .  •  r       i 

confined  in  the     the  Opening    in    the   posterior    portion  of   the 
pockets  of  the     menibrane,  iust  above  the  centre  and  near  its 

membrane.  '  J 

peripheral  attachment.  It  may  also  appear 
above  the  posterior  fold  and  be  entirely  within  the  membrana 
flaccida.  When  this  occurs  it  usually  forms  the  apex  of  an 
irregular  conical  projection  from  Shrapnell's  membrane,  the 
margins  of  the  perforation  being  swollen  and  irregular  in 
outline. 

Forcing  air  into  the  middle  ear  through  the  Eustachian 
tube  before  perforation  has  taken  place  may  not  reveal  the 
presence  of  fluid,  since  the  collection  may  be  confined  entirely 
to  the  vault.  After  perforation  has  taken  place,  even  vig- 
orous efforts  at  inflation  may  not  force  air  through  the  open- 
ing in  the  drum  membrane,  and  give  rise  to  the  characteristic 
perforation  whistle.  It  may  even  fail  to  force  any  secretion 
from  the  tympanic  cavity  on  account  of  the  extreme  swelling 
of  the  lining  membrane. 

B.  Functional  Examination. — The  functional  examination  in 
these  cases  reveals  a  condition  identical  with  that  described 
in  the  preceding  chapter  on  acute  catarrhal  otitis  media. 

When  the  labyrinth  is  encroached  upon  by  extension 
through  the  oval  or  round  window,  we  find,  in  addition,  the 
diminution  in  bone  conduction  and  loss  of  perception  of  upper 
notes  of  the  scale. 

Prognosis. — An  otitis  media  of  this  variety  can  only  ter- 


PROGNOSIS. 


343 


minate  in  spontaneous  recovery  without  loss  of  tissue  when 
the  intlammatory  process  does  not  progress  beyond  the  stage 
of  congestion.  When  once  pus  is  formed  it  must  be  evacu- 
ated, and  hence  resolution  is  impossible  after  this  period. 
With  the  evacuation  of  the  fluid  the  perforation  may  heal  and 
the  parts  be  restored  to  their  normal  condition.  Such  a  for- 
tunate termination  is  seldom  to  be  looked  for,  however,  un- 
der the  most  favorable  conditions,  and  cases  which  are  un- 
treated usually  present,  after  the  disease  has  run  its  course,  a 
destruction  of  the  membrana  tympani  over  a  greater  or  less 
area. 

The  internal  wall  (jf  the  middle  ear  may  be  covered  bv  a 
cicatrix  extending  from  the  margins  ol  the  opening  in  the 
tympanic  membrane  to  the  osseous  wall  of  the  middle  ear, 
practically  converting  it  into  a  closed  cavity.  In  other  in- 
stances where  the  membrana  tympani  has  been  almost  com- 
pletely destroyed  we  tuid  the  internal  wall  presenting  a  j)ale, 
glazed  appearance;  the  })arts  are  perfectly  dry.  and  the  mu- 
cous membrane  has  become  changed  to  one  which  does  not 
secrete  moisture.  Again,  the  internal  wall  ot  the  tympanum 
may  be  somewhat  thickened  and  moistened  by  its  normal 
mucous  secreti(jn  without  any  discharge  aj)pearing  in  the 
canal.  The  ossicular  chain  is  usually  bound  down  to  the  in- 
ternal tympanic  wall  at  various  points  by  cicatricial  bands. 
The  amount  of  interference  with  the  function  varies  in  differ- 
ent cases  and  depends  uj)on  the  location  oi  adhesions. 

In  the  majority  of  instances,  in  cases  which  have  been  un- 
treated during  an  acute  attack,  a  chronic  purulent  otitis  de- 
velops, and  careful  investigation  will  show  areas  of  bony 
necrosis  either  in  the  walls  of  the  tympanum  or  confined  to 
the  ossicular  chain.  The  location  of  the  perforation  and  its 
diagnostic  significance  in  cases  where  the  discharge  persists 
will  be  more  fully  dwelt  upon  in  the  consideration  of  chronic 
purulent  otitis  media. 

Death  may  result  from  the  disease,  from  direct  invcjlve- 
nicnt  of  the  cranial  contents,  either  directly  or  after  the  devel- 
opment of  mastoid  inflammation.  This  last  comjilication  is 
of  common  occurrence  where  the  disease  does  not  come  un- 
der observation  in  the  acute  stage.  The  prognosis  as  to  the 
integrity  of  function  is  rather  better  than  might  be  expected 
when  we  consider  the  extensive  loss  of  substance  which  the 
malady  entails.     Serious  labyrinthine  involvement  is  decid- 


344 


ACUTE    PURULENT    OTITIS    MEDIA. 


edly  the  exception,  and  when  the  labyrinth  is  involved  the  in- 
vasion is  usually  primary,  dependent  upon  the  same  cause 
as  has  produced  middle-ear  inflammation,  rather  than  as  sec- 
ondary to'the  tympanic  disease. 

Treatment. — Vigorous  measures  must  be  instituted  in  the 
earliest  stages  if  we  hope  to  abort  the  affection.  When  in' 
the  course  of  an  acute  infectious  disease  severe  pain  is  com- 
plained of  in  the  ear,  and  inspection  reveals  the  character- 
istic congestion  already  mentioned,  immediate  local  depletion 
should  be  instituted.  As  much  blood  as  the  general  condi- 
tion of  the  patient  will  permit  should  be  abstracted  from  the 
region  in  front  of  the  tragus.  The  administration  of  an  opi- 
ate to  relieve  pain  is  not  advisable  in  these  cases,  since  what- 
ever measures  are  to  be  instituted  for  the  relief  of  the  local 
condition  must  be  employed  in  the  course  of  a  few  hours,  and 
it  is  unwise  to  mask  any  advance  of  the  disease  by  blunting 
the  susceptibility  of  the  patient  to  the  intensity  of  the  pain. 
If  local  depletion  does  not  produce  immediate  relief,  the  parts 
should  be  thoroughly  incised.  This  operation  is  intensely 
painful,  but  quickly  performed,  and  the  wisdom  of  admin- 
istering a  general  anaesthetic  must  depend  upon  the  general 
condition  of  the  patient.  The  local  application  of  cocaine  to 
the  region  to  be  operated  upon  scarcely  renders  the  proced- 
ure less  painful,  although  it  is  wise  to  obtain  whatever  aid  we 
may  in  this  manner.  The  incision  should  lie  above  the  short 
process  of  the  malleus  and  posterior  to  it.  The  knife  is  en- 
tered just  behind  the  processus  brevis  and  carried  upward 
and  inward  parallel  to  the  neck  of  the  malleus  until  it  has 
pierced  the  cellular  tissue  within  the  tympanic  vault  and  im- 
pinges upon  the  bony  w^all.  The  knife  is  then  swept  back- 
ward to  the  periphery  of  the  membrane,  the  deep  tissues 
being  divided  throughout  the  entire  extent  of  the  incision. 
If  the  long  process  of  the  incus  is  encountered,  as  may  hap- 
pen if  it  lies  high  up  in  the  cavity,  or  if  the  incision  is  carried 
a  little  too  low,  care  must  be  taken  not  to  displace  it,  the  knife 
being  allowed  to  glide  over  it,  and  afterward  being  pushed 
inward  to  the  original  depth  to  complete  the  incision.  It  is 
well,  also,  on  reaching  the  periphery,  to  extend  the  section 
directly  outward  along  the  supero-posterior  wall  for  a  distance 
of  a  quarter  of  an  inch,  dividing  all  the  soft  parts  down  to 
the  bone.  Very  free  bleeding  follows  this  operation,  and  the 
haemorrhage  should  be  encouraged  by  irrigation  of  the  canal 


T  R  E  A  T  .\  I E  N  T— 1 N'  C I S 1 0  N . 


345 


with  warm  boiled  water.  It  is  to  be  distinctlv  understood 
that  we  do  not  expect  to  liberate  pus  bv  this  procedure,  but  to 
prevent  its  formation.  Consequently  the  greatest  care  must  be 
taken  that  the  field  of  operation  is  in  an  aseptic  condition,  and 
that  all  instruments  and  the  fluid  used  subsequentlv  in  irrigat- 
ing the  region  are  thoroughly  aseptic.  This  measure,  when 
performed  sufficiently  earlv.  mav  completely  abort  the  at- 
tack; the  divided  tissues  unite  firmly  at  the  end  of  a  few 
davs,  and  all  symptoms  referable  to  the  car  may  disappear 
completely.  When  seen  at  a  later  period,  and  wlien  the  parts 
are  distinctly  bulging,  it  is  wise  to  vary  the  procedure  to  the 
extent  of  beginning  the  incision  over  the  area  of  the  greatest 
bulging,  remembering  that  our  object  is  to  incise  the  vascu- 
lar tissues  located  in  the  superior  portion  of  the  cavity,  and  to 
liberate  any  contained  fluid  as  well.  Here,  instead  of  carry- 
ing the  incision  outward  uj)()n  the  canal  wall,  the  knife  may 
be  plunged  directly  into  the  most  prominent  j)orti()n  of  the 
tumor,  carried  deeply  into  the  tympanic  vault,  and  the  parts 
divided  directly  upward  as  far  as  the  superior  margin  of  the 
meatus  (Figs.  87  and  97);  the  peripheral  attachment  of  the 
membrane  posteriorly  should  then  be  followed  downward  for 
a  short  distance,  thus  fortning  a  triangular  flap,  to  favor  free 
drainage.  When  spontaneous  jicrforation  has  taken  place  we 
usually  find  it  necessary  to  enlarge  the  opening.  This  meas- 
ure should  be  carried  out  according  to  the  rule  which  gov- 
erns the  primary  incision. 

Upon  the  appearance  of  discharge  after  spontaneous  rup- 
ture, or  after  surgical  interference,  the  canal  must  be  kept  as 
free  as  possible  by  frequent  irrigation  with  a  warm  antiseptic 
solution.  This  not  only  tends  to  relieve  pain  by  depleting 
the  tissues,  but  is  of  the  greatest  importance  in  preventing  a 
localized  infection  of  the  canal.  The  development  of  a  fu- 
runcle during  the  course  of  the  disease  is  to  be  especially 
avoided,  as  it  may  mask  an  involvement  of  the  mastoid  pro- 
cess, or  may  be  mistaken  for  this  condition.  A  localized  tu- 
mefaction of  the  canal  indicative  of  mastoid  involvement  is 
situated  at  the  fundus,  upon  the  postero-superior  wall  of  the 
meatus,  and  close  to  the  drum  membrane  (Fig.  78).  In  this 
region  the  development  of  a  primary  infectious  process  in  the 
canal  wall  is  exceedingly  rare,  circumscribed  otitis  externa 
usually  occurring  in  the  fibro-cartilaginous  portion.  Tender- 
ness upon  deep  pressure  over  the  mastoid,  care  being  taken 


346  ACUTE    PURULENT    OTITIS    MEDIA. 

not  to  communicate  any  motion  to  the  movable  part  of  the 
canal  during  the  examination,  will  also  aid  us  in  deciding 
that  the  mastoid  is  involved,  while  tenderness  on  pressure 
about  the  ear,  which  imparts  a  certain  amount  of  motion  to 
the  fibro-cartilaginous  portion  of  the  meatus,  or  on  traction 
upon  the  auricle,  will  point  to  a  circumscribed  external  otitis 
of  a  simple  character. 

When  the  symptoms  point  to  mastoid  involvement,  great 
caution  is  necessary  in  order  that  measures  may  be  undertaken 
at  a  sufficiently  early  period  to  prevent  this  complication. 
With  the  accession  of  any  tenderness  over  the  mastoid  region, 
either  directly  over  the  antrum  or  at  the  apex,  the  Leiter  coil 
or  aural  ice  bag  should  be  immediately  applied  and  kept  in 
position  continuously  for  a  period  of  at  least  thirty-six  hours. 
In  addition  to  this,  attention  should  be  given  to  the  primse  vias. 
The  diet  should  be  light,  and  any  tendency  to  constipation 
should  be  overcome  by  the  free  use  of  saline  cathartics.  Any 
tumefaction  of  the  tissues  at  the  upper  and  posterior  part  of 
the  bony  meatus  close  to  the  drum  membrane  should  be  im- 
mediately incised,  since  the  relief  of  tension  here,  in  conjunc- 
tion with  cold  externally  and  frequent  irrigation  of  the  canal, 
will  usually  abort  the  attack.  Here,  again,  it  is  not  advisable 
to  administer  drugs  for  the  purpose  of  relieving  pain,  or  cer- 
tainly not  for  any  long  period.  If  the  pain  in  the  mastoid 
region  remains  moderate  for  twenty-four  hours,  and  manipu- 
lation elicits  an  increase  in  the  amount  of  tenderness,  it  may 
be  wise  to  insure  a  fair  amount  of  sleep  for  one  night  by 
the  administration  of  morphine.  This  plan  should  not  be 
repeated,  for  if  on  the  following  day  no  marked  amelioration 
of  the  symptoms  is  present,  operative  measures  directed  to 
the  mastoid  process  should  be  at  once  instituted.  I  can  hardly 
speak  favorably  of  local  bloodletting  over  the  mastoid  region. 
Occasionally  it  may  be  followed  by  relief;  but  my  experience 
has  been  that,  where  blood  has  been  abstracted  from  this  re- 
gion, the  symptoms  have  been  delayed  only,  but  the  complica- 
tion has  not  been  prevented.  Another  objection  to  local  blood- 
letting lies  in  the  fact  that  the  tenderness  of  the  parts  to  which 
the  measure  gives  rise  may  mask  that  due  to  the  inflammation 
of  the  osseous  structures.  This  is  not  a  serious  objection,  to 
be  sure,  and  a  little  care  on  the  part  of  the  surgeon  will  enable 
him  to  distinguish  between  superficial  and  deep  tenderness. 
At  the  same  time  it  is  important  for  us  to  recognize  the  fact 


TREATMENT— MASTOID    INVOLVEMENT. 


347 


of  mastoid  involvement  as  soon  as  it  takes  f)lace,  and  not  delay 
prompt  interference.  Any  measures  which  temporarily  re- 
lieve the  symptoms,  or  cause  the  disease  to  progress  more 
slowly,  are  of  decided  disadvantage,  and  often  a  menace  to 
life.  The  particular  operative  measures  to  be  adopted  when 
the  mastoid  is  involved  will  be  fully  described  in  the  section 
devoted  to  surgery.  It  should  be  stated  here,  however,  that 
the  author  is  decidedly  averse  to  the  emplovment  of  a  sim- 
j)le  incision  over  the  mastoid  in  these  cases.  The  value  of 
the  so-called  "Wilde's  incision"  depends  upon  the  depletion 
and  a  certain  amount  of  relief  to  tension  secured  by  division 
of  the  periosteum.  The  operation  is  exceedinglv  painful,  and 
a  general  anaesthetic  is  usuallv  necessarv.  In  all  cases  where 
the  Wilde  incision  is  positivelv  demanded  it  will  probably  be 
necessary  to  enter  the  mastoid  at  a  later  period,  and  to  give 
the  patient  an  anaesthetic  upon  one  day,  for  the  purpose  of 
making  a  superficial  incision,  and  to  repeat  it  a  day  later, 
for  the  purpose  of  coinpleting  the  operation  and  enter- 
ing the  mastoid  j)rocess  itself,  is  absolutclv  unjustifiable. 
When,  therefore,  external  incision  seems  indicated,  but  the 
surgeon  does  not  feel  justified  in  entering  the  bone,  it  is  much 
better  to  wait  for  twenty-four  or  forty-eight  hours,  at  which 
time  no  doubt  will  exist  as  to  the  proper  course  to  pursue. 
Incision  witiiin  the  canal  has  already  been  spoken  of,  and  is 
in  reality  an  internal  Wilde's  incision.  The  pneumatic  cells 
of  the  mastoid  are  located  much  nearer  the  superior  wall  of 
the  meatus  than  to  the  external  surface  of  the  mastoid  cortex. 
This  incision  in  the  canal  frequently  relieves  tension  suffi- 
ciently to  prevent  an  extension  of  the  inflammation.  When- 
ever internal  incision  will  not  relieve  the  condition  within  the 
mastoid,  external  incision  certainly  will  not,  and  in  adults  it 
should  be  a  cardinal  rule  never  to  depend  upon  the  operative 
measure  of  dividing  the  soft  parts  alone.  In  children  under 
three  years  of  age,  where  the  mastoid  cortex  is  thin  and  the 
cells  mav  be  opened  with  a  stout  scalpel,  the  procedure  may 
occasionallv  be  justifiable  ;  but  even  here  experience  has 
taught  me  that  a  complete  operation  under  general  anaesthesia 
is  better  than  to  incise  the  superficial  structures  simply  and 
secure  imperfect  drainage.  The  opening  must  be  small,  and 
no  knowledge  of  the  extent  of  the  tissue  involved  can  be 
gained,  while  the  exit  to  the  discharge  can  not  be  free. 
Therefore,   whenever  any  operative  procedure   is  instituted 


348  ACUTE    PURULENT    OTITIS    MEDIA. 

upon  the  mastoid  it  should  be  thorough,  and  should  be  per- 
formed under  general  anaesthesia. 

We  occasionally  meet  with  cases  which,  after  incision  of 
the  membrana  tympani  and  the  establishment  of  drainage, 
progress  favorably  for  a  certain  period,  after  which — proba- 
bly because  of  a  fresh  access  of  inflammation — the  discharge 
increases  in  amount,  the  pain  returns,  and  the  symptoms  are 
repeated,  although  not  to  the  same  degree.  Here  it  is  neces- 
sar}'  to  re-incise  the  drum  membrane  and  thoroughly  evacuate 
the  contents  of  the  tympanic  cavit}-.  Each  recurrence  incurs 
the  danger  of  mastoid  inflammation,  and  to  delay  the  estab- 
lishment of  free  drainage  through  the  external  meatus,  in  the 
hope  that  the  inflammatory  process  may  disappear  spontane- 
ously, is  certainly  unwise.  If  the  f)arts  are  kept  thoroughly 
cleansed  and  attention  is  paid  to  the  proper  exit  of  the  dis- 
charge, very  little  local  treatment  is  necessary  aside  from  this. 
Occasionally,  owing  to  the  impoverished  general  condition 
of  the  patient,  or  to  some  obstructive  lesion  in  the  upper  air 
passage,  especially  to  enlargement  of  the  pharyngeal  tonsil  in 
children,  the  discharge  becomes  small  in  amount  and  assumes 
a  watery  character,  but  does  not  cease  completely.  Here 
attention  to  the  general  health  is  of  prime  importance,  since 
if  the  discharge  is  allowed  to  continue  too  long  the  ossicles 
are  apt  to  become  involved,  and  a  chronic  purulent  otitis  may 
be  established.  If  the  pharyngeal  vault  is  the  seat  of  adenoid 
vegetations,  these  should  be  removed. 

In  case  the  discharge  does  not  cease  as  promptly  as  might 
be  expected,  owing  to  inattention  on  the  part  of  the  patient 
regarding  thorough  cleansing  of  the  canal,  granulation  tissue 
may  develop  along  the  margins  of  the  incision  or  spon- 
taneous perforation  in  the  membrana  tympani,  or  the  mucous 
membrane  within  the  tympanic  cavity  may  becojne  greatly 
hypertrophied  and  protrude  through  the  perforation  in  the 
form  of  a  pedunculated  mass,  constituting  an  aural  polyp, 
so  called.  This  obstructs  the  free  outflow  of  the  secretion, 
and  must  be  either  removed  or  destroyed  in  situ.  Removal 
ma}'  be  easily  effected  by  means  of  a  delicate  snare  armed 
with  fine  wire.  For  destroying  these  exuberant  granulations 
either  chromic  acid  or  the  fused  bead  of  nitrate  of  silver  may 
be  used.  Care  should  be  taken  to  thoroughly  dry  the  granu- 
lations before  the  escharotic  is  applied  and  to  make  the  ap- 
plication to  the  hypertrophied  tissue  onl}-,  and  not  allow  it  to 


TREATMENT— DRAINAGE. 


349 


spread  to  the  surrounding  parts.  This  is  effected  by  lightly 
touching  the  parts  which  have  been  cauterized  with  a  pledget 
of  dry  cotton  immediately  after  cauterization,  to  remove  any 
excess  of  the  agent  employed.  If  delicately  executed,  the 
procedure  is  not  painful,  but  it  is  alwa3^s  wise  to  ancesthe- 
tize  the  part  with  a  ten-per-cent  solution  of  cocaine,  previous 
to  cauterization.  Chromic  acid,  I  think,  is  the  safer  agent  to 
employ,  as  nitrate  of  silver  is  sometimes  followed  by  a  rather 
sharp  reaction. 

Again,  the  hypcrtrophicd  covering  of  the  internal  tym- 
panic wall,  instead  of  assuming  a  distinctlv  polvpoid  appear- 
ance, may  present  as  a  diffuse  thickened  membrane.  This 
occurs  especially  when  the  perforation  is  of  large  size,  expos- 
ing the  tympanum  over  a  considerable  area.  Here  we  make 
use  of  the  metallic  astringent  salts  in  aqueous  solution,  nitrate 
of  silver  being  the  favorite,  although  sulphate  of  copper,  sul- 
[)hate  of  zinc,  chloride  of  zinc,  or  the  persulphate  of  iron 
may  be  employed  jir()bai)lv  with  equally  good  results.  The 
strength  of  the  solution  used  must  vary  with  the  special  con- 
dition of  the  parts.  It  is  always  well  to  test  the  susceptibility 
of  the  patient  by  beginning  with  weak  solutions  and  to  in- 
crease the  strength  according  to  indications.  The  silver  solu- 
tions may  be  used  in  strengths  of  from  two  to  fifty  per  cent; 
the  zinc  salts  in  strengths  of  from  two  to  four  per  cent.  If 
sulphate  of  copper  is  employed  the  degree  of  concentration 
should  not  exceed  ten  or  fifteen  grains  to  the  ounce. 

The  persulphate  of  iron  seems  to  be  of  particular  value  in 
causing  a  rapid  disappearance  of  granulations  developed  about 
the  margins  of  a  perforation.  The  solution  may  be  used  full 
strength  or  diluted  with  water,  according  to  the  size  and 
character  of  the  granulatit)ns.  The  patient  should  be  seen 
the  day  following  such  applications,  as  occasionally  the  re- 
action will  cause  closure  of  the  opening. in  the  drum  mem- 
brane, and  symptoms  dependent  upon  pus  retention  may  su- 
pervene. 

When  only  a  small  quantity  of  discharge  remains  we  may 
find  that  the  use  of  fluid  in  the  canal  increases  rather  than 
diminishes  the  amount  of  discharge.  If  the  case  is  watched 
closely,  astringent  or  antiseptic  powders  may  be  employed, 
care  being  taken  that  the  opening  in  the  membrana  tympani 
is  not  occluded,  the  powder  being  insufflated  so  as  to  form 
a  thin  covering:  over  the  membrana  and  the  canal  walls.     If 


350  ACUTE    PURULENT   OTITIS   MEDIA. 

this  plan  is  adopted  the  patient  must  be  seen  daily  by  the 
surgeon  and  the  parts  thoroughly  cleansed  by  means  of  the 
cotton  pledget,  after  which  the  powder  is  lightly  dusted  oyer 
the  membrana  tympani,  the  granulations,  or  the  exposed  wall 
of  the  middle  ear,  as  the  case  may  be.  We  may  use  boric 
acid,  iodoform,  iodol,  or  dermatol.  When  the  walls  of  the 
canal  appear  sodden  from  long-continued  irrigation,  the  addi- 
tion of  a  small  amount  of  oxide  of  zinc  to  any  of  the  above 
powders  is  desirable.  This  protects  the  denuded  lining  of  the 
meatus  and  favors  the  formation  of  normal  epithelium.  After 
the  opening  in  the  drum  membrane  is  closed,  inflation  should 
be  employed  at  first  daily,  the  interval  being  increased  as  the 
parts  resume  their  normal  appearance.  It  is  important  that 
this  plan  should  be  carried  out;  otherwise  adhesions  may 
develop  in  the  tympanum  and  the  function  of  the  organ  be 
decidedly  impaired. 


CHAPTER    XXT. 

CHRONIC    CATAKKHAI,    OTITIS    MKDIA. 

Under  chronic  catarrh  of  the  niiddlc  car  various  afTcctions 
of  the  tympanum  have  been  described.  The  selection  of  this 
name  is  particularly  unfortunate,  since  it  convevs  the  impres- 
sion that  the  disease  is  really  a  complicating^  lesion  of  some 
condition  in  the  nose  or  naso-pharynx.  "Catarrhal  deafness" 
is  a  term  which  appears  not  only  in  our  standard  works  upon 
otologv.  but  also  forms  a  prominent  feature  of  the  advertise- 
ment of  almost  everv  charlatan. 

In  the  first  place,  catarrh  as  a  disease  does  not  exist,  it 
beino^  merelv  a  term  used  to  describe  a  svmptom,  meaning^ 
from  its  derivation  simj)lv  a  dischari^e.  liv  common  consent 
catarrhal  inflammation  is  the  term  applied  to  a  simple  inflam- 
mation of  anv  mucous  membrane.  It  mav  occur  in  the  ear 
or  elsewhere,  constitutinij^  a  j)rimarv  disease  entirelv  inde- 
pendent of  anv  lesion  in  the  u|)per  air  passages. 

When  the  mucous  membrane  of  the  middle  ear  is  the  seat 
of  such  a  chronic  inllammatorv  process  tiic  ciianges  which 
take  place  are  of  two  varieties:  In  one  form,  which  may  be 
termed  a  hvpertro|)hic  inflammation,  we  have  a  swelling  of 
the  lining  membrane  of  the  tympanum,  due  usually  at  first 
to  a  chronic  venous  congestion  ;  this  continuing  for  a  long 
period  results  in  hvpertrophy  of  the  elements  of  the  tissue 
lining  the  cavity.  Over  the  bony  internal  wall  of  the  mid- 
dle ear  the  mucous  membrane  is  thickened  and  hyperaemic 
and  the  glandular  elements  produce,  therefore,  an  excessive 
amount  of  secretion.  In  the  drum  membrane  the  same  pro- 
cess takes  place ;  the  fibrous  layer  becomes  thickened  in 
places,  and  may  over  certain  areas  be  the  seat  of  calcareous 
deposits.  The  same  changes  take  place  in  the  ossicles,  liga- 
ments, and  in  the  walls  of  the  Eustachian  tube.  Owing  to 
the  chronic  hyperaemia,  serum  or  sero-mucus  may  collect  in 
the  cavity  and  remain  there  permanently,  or  the  fluid  may  dis- 
appear from  time  to  time  when  the  congestion  is  less  marked. 

(35») 


352  CHRONIC    CATARRHAL    OTITIS   MEDIA. 

In  contradistinction  to  these  changes,  we  find  in  another 
class  of  cases  a  process  characterized  by  tissue  hyperplasia 
rather  than  by  hypertrophy  ;  the  new  tissue  is  firm  and  fibrous 
in  character,  secretion  is  diminished,  the  walls  of  the  ves- 
sels supplying  the  parts  are  thickened,  and  a  true  sclerosis 
results.  In  this  form  of  inflammation  the  favorite  site  of  the 
inflammatory  process  is  the  region  of  the  oval  and  round  win- 
dows. The  outer  wall  of  the  tympanum — that  is,  the  mem- 
brana  tympani— may  present  almost  no  variation  from  the  nor- 
mal appearance.  In  the  Eustachian  tube  the  tissue  changes 
cause  an  actual  increase  in  the  calibre  of  the  canal  as  the  mem- 
brane becomes  firmer  and  more  closely  applied  to  the  parts 
beneath.  In  the  tympanic  ligaments  this  sclerotic  process  in- 
creases their  firmness,  binding  the  ossicles  rigidly  together 
and  fixing  them  firmly  within  the  cavity,  so  that  the  degree 
of  motion  in  every  direction  is  much  reduced.  About  the  sta- 
pedial niche  we  find  dense  connective-tissue  bands  running 
from  the  head  of  the  stapes  and  from  the  crura  to  the  walls 
of  the  pelvis  ovalis.  The  motion  of  this  ossicle  is  therefore 
greatly  limited.  At  the  round  window  similar  changes  pre- 
vent the  compensatory  movements  of  the  membrana  tympani 
secondaria  and  render  the  vibratory  motion  of  the  labyrin- 
thine fluid  difficult  or  impossible.  Whether  the  hyperplastic 
form  of  inflammation  is  often  secondary  to  the  hypertrophic 
form  is  a  mooted  question,  but  the  weight  of  evidence  seems 
to  favor  this  view. 

Chronic  Hypertrophic  Otitis  Media. 

iEtiology. — A  chronic  hypertrophic  inflammation  within 
the  tympanum  may  follow  an  acute  catarrhal  otitis,  an  acute 
congestion  of  the  Eustachian  tube  w^hich  has  failed  to  resolve 
completely,  or  a  similar  process  in  which  the  middle  ear  and 
tube  are  both  involved.  It  may  also  occur  as  an  idiopathic 
affection,  the  organ  never  having  been  the  seat  of  an  acute  in- 
flammation. In  any  case  where  the  disease  is  chronic  from 
the  beginning  it  depends  upon  some  fault  in  the  manner  of  life 
of  the  patient  through  which  he  becomes  particularly  suscep- 
tible to  vascular  changes  in  those  portions  of  the  body  lined 
w^ith  mucous  membrane.  Frequent  exposure  to  cold  result- 
ing in  repeated  attacks  of  acute  rhinitis  or  acute  naso-pharyn- 
gitis,  from  which  the  vessels  within  the  tympanum  are  fre- 
quently engorged  with  blood,  is  a  most  common  cause.     The 


ETIOLOGY. 


353 


condition  mav  bci^in  in  early  life  from  the  presence  of  a  mod- 
erate amount  of  adenoid  tissue  in  the  pharyngeal  vault,  not 
enough  to  give  rise  to  svmptoms  of  nasal  obstruction,  but  suf- 
ficient to  cause  a  venous  engorgeiuent  of  its  parts  with  each 
exposure  to  cold.  This  condition  interferes  with  the  intra- 
tvmpanic  circulation,  and,  although  the  pharyngeal  tissue  mav 
become  entirely  normal  in  later  lite,  the  changes  set  up  within 
the  middle  ear  may  persist  and  even  increase  although  the 
cause  of  the  affection  has  disappeared.  The  disease  is  more 
commonlv  met  with  in  individuals  wh(^se  occupation  renders 
exposure  to  inclement  weather  a  matter  of  necessitv  :  it  is 
hence  more  common  in  males  than  in  females.  No  period  of 
life  is  exempt  from  the  disease,  but  it  occurs  more  frequently 
between  the  ages  of  fifteen  and  thirtv-tive  than  before  or  after 
this  period.  Marked  impairment  of  the  general  health,  either 
from  a  severe  illness,  from  j)rolonged  mental  anxictv,  or  from 
privation,  constitutes  a  factor  in  the  causatit)n  of  manv  cases. 
The  abuse  of  alcohol  also  exerts  a  certain  effect  in  the  pro- 
duction of  the  disease,  both  from  its  local  action  upon  the  di- 
gestive organs  and  its  influence  upon  the  circulatory  system. 
We  are  often  told  that  the  aural  lesion  is  due  to  the  extension 
of  inflammation  from  the  pharvngeal  vault  because  of  the  con- 
tinuitv  of  anatomical  structure.  While  this  may  be  so,  it  is 
certainly  a  question  of  little  importance,  since  the  same  causes 
acting  to  produce  the  pharvngeal  inflammation  mav  exert 
their  effect  primarilv  upon  the  lining  membrane  of  the  tym- 
panum. The  excessive  use  of  tobacco  is  not  responsible  for 
the  disease  under  consideration,  except  as  it  may  affect  the 
general  health;  the  inhalatit)n  of  smoke  produces  quite  as 
deleterious  an  effect  upon  the  respiratory  organs  and  middle 
ear  from  local  action  as  does  the  actual  use  of  the  weed. 

The  opinion  so  prevalent,  that  imj)aired  hearing  due  to 
catarrhal  inflammation  of  the  tvmpanum  is  to  a  certain  extent 
hereditarv,  is  n(^t  entirelv  borne  out  by  experience.  A  care- 
ful examination  of  statistics  shows  that  in  the  disease  under 
consideration  hereditv  plays  a  verv  unimportant  part  in  the 
causation.  It  is  true  that  certain  families  seem  to  show  a 
particular  predisposition  to  inflammations  of  the  lymphatic 
type,  engorgement  of  the  Ivmph  nodules  occurring  with  any 
slight  local  inflammation.  This  is  seen  if  we  observe  the  fre- 
quency with  which  adenoid  vegetations  are  observed  in  dif- 
ferent members  of  the  same  family  through  several  genera- 
24 


354 


CHRONIC    CATARRHAL    OTITIS   MEDIA. 


tions.  Since  these  growths  exert  an  influence  upon  tympanic 
conditions,  it  is  not  strange  that  the  belief  should  be  held  that 
the  aural  affection  is  transmitted  from  one  generation  to  an- 
other. In  many  cases,  however,  we  find  the  pharyngeal  lym- 
phatics enlarged  through  several  generations  without  any 
aural  affection.  It  is  probable,  therefore,  that  the  influence 
of  heredity  is  limited  to  the  lymphatic  deposits,  which  render 
the  ears  more  easilv  affected  by  slight  changes.  It  is  seldom 
that  any  hereditary  history  of  the  aural  disease  is  met  with 
without  the  accompanying  lymphatic  taint. 

Pathology. — The  pathological  changes  have  been  described 
somewhat  at  length  in  the  introductory  remarks.  To  recapit- 
ulate, they  consist  in  a  swelling  of  the  lining  membrane  of  the 
tympanum,  due  at  first  to  a  venous  congestion,  but  afterward 
to  an  actual  tissue  hypertrophy.  The  newly  formed  tissue 
is  vascular  and  richly  supplied  with  cellular  elements,  the 
fibrous  elements  being  but  little  developed.  An  actual  in- 
crease in  volume  is  the  result  of  this  process,  and  is  charac- 
teristic of  this  form  of  inflammation.  The  presence  within 
the  tympanum  of  a  fluid  exudation,  due  either  to  an  abnor- 
mal activity  of  the  secretory  glands  or  to  the  transudation  of 
the  fluid  elements  of  the  blood  from  the  engorged  vessels, 
constitutes  another  prominent  feature.  No  particular  por- 
tion of  the  middle  ear  is  involved  by  preference,  even  the 
membrana  tympani  sharing  in  the  changes  w^rought  bv  the 
morbid  process.  In  the  membrana  tympani  there  is  thicken- 
ing of  the  mucosa  and  swelling  of  the  fibrous  layer,  followed 
by  true  hypertrophy  here,  and  in  the  advanced  stages  by  a 
deposit  of  the  lime  salts. 

As  involving  the  drum  membrane,  the  structural  changes 
produced  are  usuall}  more  marked  in  some  parts  of  the  mem- 
brana  tympani  than  in  others.  This  results  in  an  irregularity 
of  texture,  some  portions  appearing  dense  and  opaque,  while 
others,  by  contrast,  appear  thinner  than  normal  (see  colored 
plates).  In  the  Eustachian  tube  the  tissue  changes  within 
the  walls  narrow  its  lumen,  and  prevent  the  entrance  of  air 
into  the  middle  ear.  This  reduces  the  tension  within  the 
middle  ear,  and  causes  depression  of  the  membrana  tympani 
from  atmospheric  pressure.  A  gradual  stretching  of  the  drum 
membrane  takes  place  from  the  continued  pressure  from  with- 
out, until  finally  further  displacement  is  prevented  by  contact 
with  the  internal  tympanic  wall.     The  pressure  against  this 


PATHOLOGY. 


355 


resisting  harrier  increases  the  local  inflammatory  process. 
The  movement  of  the  drum  membrane  inward  and  its  per- 
sistence in  this  jiosition  is  favored  by  the  action  of  the  tensor 
tvmpanic  muscle,  which  bv  contraction  draws  the  membrane 
inward  ag^ainst  the  wall  of  the  middle  ear.  From  disuse  the 
tendon  becomes  shortened,  this  chauij^e  beint::  aided  by  the 
inflammatorv  process.  if  now  the  Eustachian  tube  is  re- 
stored to  its  normal  jtatencv,  the  membraiia  t\tiipani  docs 
not  assume  its  correct  [xjsition,  and  it  may  even  be  imi)ossible 
to  replace  it  bv  artificial  means.  Similar  chani^es  occur  in 
the  intratvmpanic  lij^aments  if  the  parts  are  suffered  ^o  re- 
main misplaced  for  a  considerable  leuii^lh  of  time.  Of  the 
hgaments  which  bind  the  ossicular  chain  to^jether  the  ca[)- 
sular  ligament  of  the  malleo-incudal  articulation  sufTers  the 
most,  it  may  become  relaxed,  and  render  displacement  of 
the  ossicular  chain  more  easv.  From  the  relaxation  of  this 
ligament  the  entire  drum  membrane  and  the  tip  t)f  the  handle 
of  the  malleus  may  be  carried  directly  inward  toward  the 
tympanic  wall  by  rotati<:)n  of  the  malleus  upon  the  axis  band. 
The  separation  of  the  articular  surfaces  of  the  malleus  and 
incus  prevents  the  perfect  transmission  of  the  aerial  vibra- 
tions to  the  stapes,  and  impairment  of  function  results. 

When  the  hypertrophic  jirocess  changes  to  the  h\j)er- 
plastic  variety  the  newly  deposited  connective  tissue  be- 
comes transformed,  its  cellular  elements  disappear,  and  are 
rej)laced  bv  a  dense  fibrous  tissue,  which  by  contraction  in- 
creases the  tension  in  the  ossicular  chain. 

As  to  changes  occurring  in  the  labyrinth  from  the  process 
within  the  middle  ear.  these  may  dej)end  upon  the  pressure 
to  which  the  labyrinthine  fluid  is  subjected  Ironi  the  incieased 
tension,  although  this  factor  exists  in  the  early  stages  only. 
Labyrinthine  complications  are  not  common  in  the  hyper- 
trophic form.  The  most  prominent  element  in  their  causa- 
tion is  the  interference  with  the  labyrinthine  circulation.  Al- 
though the  communication  between  the  tympanic  and  laby- 
rinthine vessels  is  not  intimate,  hypertrophic  changes  within 
the  middle  ear  exert  an  influence  probably  upon  the  parts 
from  which  they  are  separated  only  by  the  thin  membrane  of 
the  round  window  and  by  the  fibres  of  the  annular  ligament 
in  the  fenestra  ovalis.  A  large  portion  of  the  venous  blood 
from  the  labyrinth  enters  the  general  circulation  through 
the  vena   aqua:ductus   cochleae,   which    leaves  the    labyrinth 


356  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

close  to  the  round  window.  Hence  any  increased  vascular- 
ity wathin  the  tympanum  affects  the  venous  flow  through  this 
channel  both  by  mechanical  pressure  and  by  the  change  in 
the  rapidity  of  the  flow  of  the  blood  current.  The  actual 
communication  between  the  vessels  of  the  middle  ear  and  the 
labyrinth  has  been  demonstrated  by  Cassebohm  *  the  anas- 
tomosis taking  place  at  the  round  window.  Buck  has  dem- 
onstrated a  similar  communication  at  the  oval  window.  The 
perforating  vessels,  which  Politzer  claims  to  exist,  have  al- 
ready been  mentioned.  While,  therefore,  the  communication 
may  not  be  very  direct,  a  disturbance  of  the  circulation 
within  the  middle  ear,  if  continued  for  a  long  period,  must 
cause  changes  in  the  labyrinthine  blood  current,  and  corre- 
sponding changes  in  labyrinthine  pressure. 

Symptomatology. — The  afTection  is  usually  bilateral,  al- 
though both  organs  are  seldom  involved  to  the  same  degree. 
The  hearing  with  which  we  are  endowed  is  far  in  excess  of 
that  necessary  to  carry  on  the  ordinary  vocations  of  life,  and 
one  may  be  unconscious  of  any  impairment  of  function  until 
it  exists  to  a  marked  degree.  When  these  patients  come  un- 
der observation  they  seek  relief  either  on  account  of  the  im- 
pairment in  function  or  because  of  distressing  subjective  noises. 
The  impairment  of  function  is  usually  intermittent  in  the  early 
stages,  the  periods  during  which  the  hearing  seems  to  the 
patients  to  be  fairly  normal  having  become  gradually  shorter 
and  shorter,  until  at  last  they  seek  relief.  This  irregularity 
in  the  occurrence  of  the  symptoms  is  quite  characteristic  of 
the  hypertrophic  variety  of  inflammation  of  the  middle  ear. 
Sudden  changes  in  temperature,  indiscretions  in  diet,  or  im- 
pairment of  the  general  health  cause  the  local  symptoms  to 
increase  in  severity  on  account  of  the  changes  which  they 
effect  in  the  mucous  membrane.  The  subjective  noises  are 
usually  more  pronounced  upon  one  side  than  upon  the  other, 
and  the  same  is  true  of  the  impairment  in  hearing.  These 
symptoms  may  be  more  marked  in  the  same  ear,  although 
where  the  disease  has  existed  for  a  long  time  we  may  find 
that  the  noises  have  entirely  disappeared  from  the  ear  first 
affected,  tinnitus  being  distressing  onlv  upon  the  opposite 
side.  Changes  in  the  position  of  the  body  may  influence  both 
the  character  and  the  degree  of  the  subjective  noises.     Quite 

*  Cited  by  Uibantschitsch,  Lehr.  der  Ohrenheilk.,  Vienna,  1891,  p.  235. 


SYMPTOMATOLOGY.  3-; 

frequentlv  thcv  are  onlv  noticed  when  the  patient  is  lying 
down.  Thev  may  be  synchronous  with  the  cardiac  pulsa- 
tions, or  niav  be  continuous.  They  are  usually  high-pitched, 
and  are  variously  described  as  singing,  hissing,  blowing,  or 
whistling  sounds.  These  subjective  noises  may  be  entirely 
drowned  by  external  sounds.  Thus  they  may  disappear  in  a 
railway  train  or  on  a  busy  thoroughfare,  but  reajipear  instant- 
ly in  a  quiet  room.  In  the  same  way  external  noises  alTect 
the  hearing  to  a  marked  degree.  Most  of  these  jnitients  are 
able  to  hear  better  in  a  noise  than  where  it  is  cpiict.  We  may 
explain  this  fact  either  upon  the  hypothesis  that  the  more  in- 
tense sounds  serve  to  set  the  ossicular  chain  in  vibration. 
after  which  sounds  of  less  intensity  are  able  to  so  modity 
this  motion  as  to  be  perceived,  although  they  are  unable  to 
overcome  intratvmpanic  rigidity  by  themselves,  or  that  loud 
sounds  produce  a  condition  of  auditory  hyperesthesia. 

Where  Huid  is  present  in  the  middle  ear,  bubbling  sounds 
may  be  complained  of  upon  forcible  attemjUs  at  clearing  the 
nostrils.  Snapj)ing  or  cracking  sounds  heard  in  the  car  with 
each  act  of  deglutition,  due  either  to  the  separation  of  the 
walls  of  the  Eustachian  tube  at  this  moment  or  to  the  entrance 
of  air  into  the  tympanum,  is  also  a  symptom  often  met  with. 
Occasionally  we  may  elicit  the  fact  that  upon  changing  the 
position  of  the  head  the  hearing  becomes  suddenly  impaired. 
This  is  frequently  due  to  the  presence  of  fluid  within  the 
tympanic  cavity,  the  change  in  position  causing  it  to  gravitate 
to  the  rejrion  of  the  oval  and  round  windows,  and  thus  to  im- 
pede  the  vibration  of  the  labyrinthine  fluid.  Occasionally 
slight  vertigo  is  complained  of.  This,  hcnvever,  is  not  severe, 
and  is  usually  attributable  to  a  sudden  change  in  intiatym- 
panic  pressure,  as  by  auto-inflation,  in  the  act  of  blowing  the 
nose,  aspiration  of  the  tvmj)anum  by  a  sudden  deep  inspira- 
tion, etc. 

Pain  is  not  common  in  these  cases,  although,  when  a  sud- 
den stenosis  of  the  tube  occurs,  the  patient  may  complain  of 
occasional  neuralgic  pains  radiating  from  the  pharynx  in  the 
direction  of  the  ear.  In  certain  rare  instances,  where  the 
chronic  inflammation  is  confined  mostly  to  the  region  of  the 
Eustachian  tube,  the  patient  may  complain  of  sharp  pain  in 
the  throat,  referred  to  the  region  of  the  lingual  tonsil,  fre- 
quently more  severe  upon  one  side.  It  is  impossible  for  the 
patient  to  locate  the  exact  painful  point,  although  frequently 


358  CHRONIC   CATARRHAL   OTITIS   MEDIA. 

it  is  referred  to  the  posterior  pharyngeal  folds  or  to  the  lymph 
tissue  at  the  base  of  the  tongue.  In  a  large  number  of  these 
cases  the  pharynx  is  entirely  healthy,  and  the  pain  is  due  to 
the  changes  in  the  Eustachian  tube.  The  true  nature  of  the 
affection  is  frequently  discovered  accidentally,  or  not  until 
changes  within  the  tympanum  have  become  so  marked  as  to 
demand  measures  for  relief.  Most  frequently  the  patient  de- 
scribes the  sensation  as  not  amounting  to  actual  pain,  but  that 
the  throat  feels  "  rough  "  or  "  burns."  In  other  cases  the  pain 
is  intense,  rendering  deglutition  difficult. 

Diagnosis. — A.  Physical  Examination.  —  The  appearance 
presented  by  the  parts  varies  according  to  the  extent  to  which 
the  process  has  advanced.  In  the  early  stages,  upon  inspecting 
the  drum  membrane,  there  may  be  no  deviation  from  the  nor- 
mal picture.  The  most  frequent  change  is  a  moderate  de- 
gree of  depression  of  the  membrana  tympani,  evidenced  by 
a  foreshortening  of  the  manubrium  mallei  and  exaggeration 
of  the  posterior  fold  (Fig.  103).  The  color  of  the  membrane 
is  either  normal,  or  there  may  be  a  slight  reddening  along 
the  malleus  handle  and  at  the  supero-posterior  border  of  the 
membrane,  together  with  a  reddish  reflex  from  the  internal 
tympanic  wall.  This  last  sign  is  considered  particularly  im- 
portant by  Schwartze,  as  indicative  of  the  fact  that  the  inflam- 
matory process  is  still  active.  The  lustre  of  the  membrane  is 
usually  slightly  diminished,  while  in  texture  it  appears  some- 
what thicker  than  normal.  This  apparent  increase  in  density 
is  usually  not  general,  but  is  more  prominent  over  certain 
areas.  An  appearance  which  is  quite  characteristic  of  the 
early  stages  is  the  rotation  of  the  malleus 
upon  its  long  axis,  which,  if  the  membrane 
is  at  the  same  time  retracted,  causes  the 
malleus  handle  to  appear  narrower  than  nor- 
mal. If  there  is  no  depression,  the  rotation 
mav  cause  the  manubrium  to  appear  abnor- 
FiG   io2.-Rotation    anally  wide  (Fig.  I02).  This  change  in  breadth 

or   malleus    about      ,  -^  ...  . 

its  long  axis  in-    is  due  to  inequalities  in  tension  of  the  intra- 

creasing  the  width     <.  •       i-  ^       /  ^\         •    a  t. 

of  the  manubrium,  tvmpanic  ligaments  from  the  mflammatorv 
process,  which  is  more  pronounced  in  cer- 
tain portions  of  the  cavity  than  elsewhere.  The  presence 
of  adhesions  or  the  irregular  tumefaction  of  the  membrane 
prevents  displacement  of  the  ossicular  chain  bv  rotation  of  the 
malleus  about  the  axis  band,  but  acts  in  such  a  manner  as  to 


DIAGNOSIS— PHYSICAL    EXAMINATION. 


359 


twist  the  ossicle  about  its  long  axis,  turning  one  of  its  pris- 
matic surfaces  toward  the  canal.  When  displacement  inward 
and  rotation  are  both  present,  a  sharp  edge  of  the  shaft 
of  the  malleus  is  presented  to  the  meatus,  thus  making  the 
shaft  appear  narrow.  The  short  process  is  usually  more 
prominent  and  whiter  than  normal.  The  position  which  it 
assumes  gives  important  information  as  to  the  direction  in 
which  rotation  has  taken  place,  and  whether  the  increased 
tension  lies  in  the  anterior  or  posterior  half  of  the  tympanum. 
The  upper  portion  of  the  membrane  aboye  the  short  j)r()ccss 
frequently  has  a  crumjiled  apj)earance  due  to  localized  areas 
of  inflammation  in  the  parts  beneath.  When  the  disease 
has  existed  lor  some  time  the  membrane  in  this  region  may 
appear  abnormally  thin,  aiul  oyer  the  neck  of  the  malleus  may 
be  adherent  and  much  depressed,  l^ressure  here  may  cause 
atrophy  of  the  fibrous  tissue,  and  may  giye  the  membrane  the 
appearance  of  haying  been  perforated  and  having  undergone 
cicatrization.  In  the  more  advanced  cases  we  find  the  niem- 
brana  vibrans  disjdaced  toward  the  j>r()m- 
ontory,  the  tip  oi  the  malleus  frequently 
imjiinging  ui)on  the  wall  of  the  middle  ear. 
It  may  be  drawn  either  toward  the  anterior 
or  posterior  wall  of  the  tympanum,  accord- 
ing to  the  distribution  of  the  connective 
tissue  within  the  cavity.  When  displaced 
backward  and  inward,  we  frecpjcntly  see  a 
tense  band  running  from  the  short  process 
downward  and  backward  until  it  is  lost 
in  the  posterior  margin  of  the  membrane 
(Fig.  103);  so  well  defined  is  this  that  it  is 
frequently  mistaken  for  the  handle  of  the 
malleus,  which  lies  in  front  of  it,  and  is  only  visible  when  the 
head  of  the  patient  is  turned  so  as  to  permit  the  light  to  be 
directed  beneath  this  fold.  Pomeroy  has  given  the  name  of 
"supernumerary  posterior  fold  "  to  this  band. 

When  there  is  fluid  within  the  t\mj)anum  the  membrana 
tympani  is  apparentU'  crossed  by  a  fine  line,  which  marks  the 
level  of  the  fluid.  This  appearance  is  only  presented  when 
the  drum  membrane  is  not  thickened  from  hypertrophic 
changes.  If  this  has  taken  place,  the  level  of  the  effusion 
can  not  be  made  out,  but  the  segment  below  the  level  of 
the   fluid  appears  more  opaque   than  the  part  above.      The 


Fl("..  103. —  Kfl  faction 
of  the  diuin  mem- 
brane ami  adhesions 
within  the  middle 
ear.  The  malleus 
handle  is  narrow, 
and  thesuperniimer- 
ar)'  posterior  fold  is 
distinct. 


360  CHRONIC   CATARRHAL   OTITIS   MEDIA. 

drum  membrane  over  the  transvidate  is  of  a  yellowish  tinge, 
the  appearance  being  more  marked  if  the  secretion  is  inspis- 
sated. Occasionally  fine  bubbles  may  be  seen,  appearing  as 
distinct  bright  points  upon  the  membrana.  Any  of  the  above 
appearances  should  make  us  suspect  the  presence  of  fluid,  and 
any  alteration  in  the  picture  after  inflation  confirms  the  opin- 
ion. If  the  membrana  tympani  has  remained  in  contact  with 
the  internal  wall  of  the  middle  ear  for  a  considerable  length 
of  time,  the  pressure  may  have  caused  partial  absorption  of 
the  fibrous  layer,  increasing  the  transparency  of  the  mem- 
brane in  this  locality.  On  the  other  hand,  areas  which  pre- 
sent evidence  of  a  hypertrophic  process  are  frequently  the 
seat  of  calcific  deposits  in  the  later  stages  of  the  disease.  The 
development  of  adhesions  between  the  membrana  vibrans  and 
internal  wall  of  the  middle  ear  is  scarcely  as  characteristic  of 
the  hypertrophic  variety  of  the  inflammation  as  of  the  hyper- 
plastic, yet  we  may  find  this  condition  present,  especially  in 
the  region  of  the  umbo,  as  this  is  the  first  point  of  contact  be- 
tween the  drum  membrane  and  the  external  tympanic  wall, 
the  displacement  being  due  both  to  atmospheric  pressure  and 
to  the  action  of  the  tensor  tympanic  muscle. 

In  certain  cases,  especially  where  frequent  auto-inflation 
has  been  practiced,  the  drum  membrane  becomes  much  re- 
laxed in  the  upper  and  posterior  quadrant,  and  when  indrawn 
applies  itself  so  closely  to  the  bony  walls  as  to  permit  the  intra- 
tympanic  landmarks  in  this  region,  such  as  the  incudo-stapedial 
articulation  and  the  niche  of  the  round  window,  to  be  clearly 
made  out  (Fig.  95).  Such  a  relaxation  of  the  membrana  is 
easily  demonstrated  if  we  request  the  patient  to  inflate  the 
ear  by  holding  the  nose,  closing  the  mouth,  and  blowing 
forcibly.  When  this  is  done  the  upper  and  posterior  seg- 
ment will  be  seen  to  move  outward  into  the  canal,  while  at 
the  same  time  the  deeper  parts  disappear  from  view. 

The  impairment  of  hearing  in  these  cases  disappears  to 
an  astonishing  extent  when  this  relaxation  is  corrected,  but 
may  reappear  upon  deglutition,  the  air  within  the  middle  ear 
being  aspirated  and  the  membrane  assuming  its  former  posi- 
tion. The  presence  of  adhesions  or  the  condition  of  relaxa- 
tion just  described  may  be  satisfactorily  demonstrated  by 
alternately  rarefying  and  condensing  the  air  in  the  meatus  by 
means  of  the  pneumatic  otoscope.  The  adherent  areas  do 
not  move,  while  the  relaxed  portions  of  the  drum  membrane 


DIAGNOSIS— PHYSICAL   EXAMINATION. 


361 


are  seen  to  make  exaj^e^erated  inward  and  (nitward  excursions, 
according  as  the  air  within  the  canal  is  condensed  or  rarefied. 

Anomalies  in  tension  of  the  intratympanic  ligaments  are 
easily  demonstrated  bv  the  pneumatic  otoscope.  Under  ma- 
nipulation the  malleus  handle,  instead  of  moving  directly  out- 
ward when  the  air  wit<iin  the  canal  is  rarefied,  will  be  seen  to 
twist  upon  its  long  axis,  the  tip  of  the  manubrium  frequently 
remaining  fixed,  while  the  slu)rt  prijcess  describes  tlie  arc  of 
a  circle.  Clinically  this  sign  is  of  inijiortance.  as  it  usually 
indicates  relaxatit)n  at  the  malleo-incudal  articulation,  and 
may  account  for  certain  subjcctiyc  svni]»t(tiiis  which  make 
their  appearance  only  when  the  patient  changes  his  position 
and  suddenly  separates  the  articular  surfaces  ol  these  ossicles. 

Inflation  by  the  catheter  or  air  bag — preferably  the  former 
— elicits  various  auscultatory  signs.  T^yidences  ol  fluid  within 
the  tympanum  have  already  been  mentioned  and  need  not  be 
repeated.  When  the  lumen  of  the  tube  is  narrowed,  the  air, 
upon  entering  the  middle  ear,  will  produce  a  high-{>itched 
sound  on  account  of  the  narrowing  of  the  canal.  This  sound 
may  be  either  moist  or  dry,  according  to  the  stage  of  the  dis- 
ease. When  the  tube  is  much  narrowed  and  the  walls  are 
covered  with  thick  secretion,  the  air  may  fail  to  enter  the 
middle  ear,  and  a  distinct  percussion  sound  will  be  recognized 
with  each  attempt  at  inflation,  as  the  air  impinges  upon  the 
mass  of  inspissated  mucus  at  the  narrow  portion  of  the  tube. 
Prolonged  effort  will  usually  dislodge  this,  after  which  the 
air  will  enter  the  cavity,  causing  a  sudden  outward  excursion 
of  the  drum  membrane,  as  evidenced  by  the  peculiar  sharp 
click  heard  as  it  is  driven  outward.  If  the  cavity  is  com- 
pletely filled  with  fluid,  absolutely  no  sound  may  be  heard. 
It  is  possible  for  the  adiiesions  to  develop  in  such  a  manner 
as  to  shut  ofl  the  greater  part  of  the  tympanic  cavity  from 
the  Eustachian  tube.  When  this  occurs,  the  air,  as  it  im- 
pinges upon  the  barrier  at  the  tyni})anic  orifice,  will  i)roduce 
a  distinct  percussion  note  similar  to  that  heard  when  an  ob- 
struction is  present  at  the  isthmus  of  the  tube,  but  not  as  re- 
mote. Marked  relaxation  of  the  drum  membrane  is  recog- 
nized by  the  peculiar  flapping  sound  which  is  heard  as  the  lax 
septum  is  forced  outward. 

Inspection  of  the  membrane  immediately  after  inflation 
will  enable  us  to  determine  over  what  areas  adhesion  has 
taken  place  between  the  internal  and  external  tympanic  walls. 


362  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

As  before  stated,  adhesion  at  the  umbo  is  not  uncommon,  and 
hence  inflation  may  produce  little  change  in  the  position  of 
the  membrane,  ahhough  the  hearing  may  be  greatly  improved 
by  the  operation  from  the  re-establishment  of  equilibrium. 

B.  Functional  Examination. — The  hearing  power  for  the 
voice  is  considerably  reduced.  The  hearing  power  for  the 
watch  or  acoumeter  is  also  diminished.  The  lower  tone  limit 
is  elevated,  and  where  the  middle  ear  alone  is  involved  the  de- 
gree of  elevation  corresponds  to  the  impairment  of  audition 
for  the  whisper  or  for  the  conversational  voice.  These  cases 
usually  hear  a  whisper  relatively  better  than  articulate  speech. 
This  is  due  to  the  fact  that  the  pitch  of  the  whisper  of  any 
ofiven  combination  of  letters  is  alwavs  the  same,  while  in  ar- 
ticulate  speech  the  same  word  or  sentence  repeated  by  differ- 
ent individuals  varies  grcatlv,  owing  to  the  presence  of  over- 
tones. The  individual  qualitv  of  the  voice  depends  upon 
these  overtones.  Hence  we  find  the  power  of  perception  for 
the  conversational  voice  varies  greatlv  according  to  the  indi- 
vidual with  whom  the  patient  converses,  with  some  the  hear- 
inor  beinor  b^t  slighllv  diminished,  while  with  others  marked 
impairment  is  evident.  The  upper  tone  limit  is  either  nor- 
mal or  slightly  lowered.  Bone  conduction  is  increased  in  the 
early  stages  of  the  disease,  the  vibrating  tuning  fork,  placed 
in  the  median  line,  being  referred  to  the  poorer  ear.  In  ad- 
vanced cases  it  may  be  referred  to  the  better  ear,  and  when 
this  is  the  case  the  prognosis  is  less  favorable.  Where  the 
upper  tone  limit  is  lowered  it  not  infrequentlv  happens  that 
the  greatest  deviation  from  the  normal  standard  is  in  the  bet- 
ter ear.  This  is  explained  upon  the  theory  that  the  increased 
labyrinthine  pressure  upon  the  side  first  affected  has  caused 
certain  changes  to  take  place  in  the  cortical  area  specialized 
for  the  perception  of  these  particular  notes.  This  area  re- 
ceives most  of  its  nerve  fibres  from  the  ear  of  the  opposite 
side,  but  a  few  come  from  the  organ  of  the  same  side.  The 
influence  of  the  tympanic  condition  upon  the  labvrinth  of  the 
organ  first  attacked  institutes  certain  cortical  changes  which 
affect  secondarily  the  nerve  fibres  derived  from  the  other  ear. 
These  secondary  changes  expended  upon  the  receptive  mech- 
anism are  more  rapid  than  the  changes  within  the  middle  ear; 
and  we  find  the  labyrinthine  degeneration  on  the  side  last 
involved  more  marked  than  in  the  organ  primarilv  affected. 
It  is  of  importance  to  recognize  this  fact  as  indicative  of  the 


PROGNOSIS. 


363 


progress  of  the  disease,  and  prompt  measures  must  be  insti- 
tuted to  curtail  the  steady  advance  of  the  affection. 

Prognosis. — The  ultimate  outcome  will  depend  uj^on  the 
cause,  the  social  condition  of  the  patient,  and  the  extent  to 
which  the  process  has  advanced  before  the  patient  comes 
under  observation. 

When  seen  in  the  early  stages  associated  with  a  flections 
either  of  the  nasal  passages  or  of  the  naso-pharvnx,  we  may 
hope  to  arrest  the  disease  completelv.  and  in  a  large  measure 
to  correct  the  damage  already  done.  The  station  in  life  oc- 
cupied by  the  j)atient  influences  the  progress  of  the  disease, 
in  so  far  as  it  necessitates  his  exposure  to  inclement  weather, 
phvsical  hardship,  sudtlen  changes  of  lieat  and  cold,  and  pro- 
l(jnged  mental  exertion.  The  age  of  the  patient  is  also  a  fac- 
tor. Thus,  if  the  impairment  of  function  is  considerable  in  a 
patient  under  thirtv  vears  of  age,  we  can  scarcelv  hope  for 
great  improvement  except  bv  the  emplovment  of  the  most 
radical  means  at  our  command;  while  the  same  degree  of  im- 
pairment  met  with  later  in  life  would  be  more  amenable  to 
treatment,  since  at  this  period  hvjiertrojthic  changes  in  the 
upper  air  passages  are  the  exception,  the  tendency  being  for 
spontaneous  absorjnion  to  take  place,  and  the  affection  might 
even  improve  spontaneouslv.  In  anv  given  case  where  the 
aural  lesion  is  associated  with  some  affection  of  the  upper  air 
passages,  we  can  usuallv  promise,  bv  restoring  these  parts  to 
their  normal  state,  to  relieve  the  jiatient  of  those  sudden  fluc- 
tuations in  hearing  dependent  uj)on  vascular  disturbances  in 
the  upper  air  passages.  At  the  same  time  the  progress  of  the 
disease  will  probablv  be  checked,  but  any  marked  improve- 
ment in  hearing  can  not  be  promised  if  the  [)aticnt  is  more 
than  thirtv  years  of  age,  although  in  many  instances  the  re- 
sults of  treatment  are  exceedingly  satisfactory.  In  young  sub- 
jects the  changes  wrought  by  thoroughly  freeing  the  upper 
air  passages  may  cause  a  retrograde  process  to  take  place  in 
the  mucous  membrane  of  the  tympanum,  and  great  improve- 
ment may  result.  The  surgeon  must  be  cautious,  however, 
regarding  the  extent  of  improvement  promised. 

Hvgienic  measures,  the  observance  of  which  renders  the 
patient  less  liable  to  colds,  must  also  be  considered.  In  cases 
of  long  standing  the  prognosis  will  depend  largely  upon  the 
presence  or  extent  of  secondary  labvrinthine  involvement,  and 
particularly  upon  the  degree  to  which  the  ear  of  the  opposite 


364  CHRONIC    CATARRHAL    OTITIS   MEDIA. 

side  is  affected.  Any  tendency  toward  secondary  sclerotic 
changes  as  evidenced  by  patency  of  the  Eustachian  tube,  or 
a  degree  of  patency  which  is  abnormal,  will  also  render  the 
prognosis  more  grave.  The  condition  of  the  tube  itself  is  of 
importance,  as  it  enables  us  to  judge  of  the  changes  which 
have  probably  taken  place  in  tympanic  adhesions.  If  the 
tube  is  of  normal  calibre  it  is  probable  that  these  have  be- 
come firm,  and  that  the  impairment  in  function  depends  upon 
this  cause.  We  can  scarcely  hope  to  absorb  a  deposit  of  long 
standing,  and  hence  our  prognosis  must  be  guarded. 

Treatment. — We  may  divide  this  into  the  treatment  of 
the  upper  air  passages,  the  treatment  of  the  Eustachian  tube, 
and  the  treatment  of  the  intratympanic  condition. 

Our  first  care  should  be  to  place  the  upper  air  passages  in 
such  a  condition  as  to  permit  free  nasal  respiration,  and  to  pre- 
vent as  much  as  possible  the  venous  engorgement  of  these 
parts  from  slight  exposure  to  cold.  From  this  we  do  not 
mean  that  slight  deviation  from  an  ideal  condition,  anatomic- 
ally speaking,  must  be  dealt  with  surgically.  If  the  nasal  pas- 
sages are  free,  and  no  evidence  of  mouth  breathing  is  present, 
the  treatment  of  this  region  can  in  no  wav  im[)rove  the  audi- 
tory function.  In  the  same  way  a  small  amount  of  lymphatic 
tissue  within  the  pharyngeal  vault  in  patients  over  twenty 
years  of  age  does  not  demand  removal  unless  it  gives  rise  to 
some  special  disturbance.  In  young  subjects,  however,  I  am 
disposed  to  deal  radically  with  any  lymphatic  hypertrophy  in 
this  region  if  there  is  the  slightest  evidence  of  impairment 
of  hearing,  since  in  early  life  lymphatic  tissue  is  particularly 
prone  to  vascular  changes  from  comparatively  slight  causes. 
Adenoid  growths,  then,  should  be  removed  surgically,  either 
by  the  forceps  or  curette,  or  absorption  effected  by  the  appli- 
cation of  chemical  agents.  Of  these,  a  solution  of  the  nitrate 
of  silver,  introduced  through  the  anterior  nares  after  the  parts 
have  been  rendered  insensitive  by  cocaine,  will  be  found  to 
be  effective.  A  solution  of  sixty  grains  of  nitrate  of  silver  to 
the  ounce  may  be  applied  to  the  part  by  means  of  the  cotton- 
tipped  probe,  care  being  taken  not  to  distribute  the  solution 
over  the  walls  of  the  nasal  cavity,  nor  to  use  it  so  freely  as  to 
allow  it  to  pass  into  the  lower  pharynx.  Hypertrophy  of  the 
turbinated  bodies,  if  excessive,  may  be  dealt  with  surgically, 
but  usually  cauterization  with  chromic  acid  will  be  sufficient. 
Obstructive  lesions  due  to  deformity  of  the  septum  may  be 


TREATMENT— INFLATION. 


365 


removed  either  with  the  saw,  trephine,  or  galvano-cautery, 
as  the  operator  deems  most  expedient. 

Concerning  the  removal  of  the  faucial  tonsils,  it  is  mv  be- 
lief that  they  may  cause  sect)ndary  engorgement  witliin  the 
naso-pharynx,  and  hence,  if  thev  are  hvpertrophied,  their  re- 
moval is  indicated  when  met  with  in  childhood  or  earlv  adult 
life.     After  this  period  this  rule  naturally  does  not  applv. 

The  Eustachian  canal  usuallv  requires  special  measures  to 
determine  its  return  to  the  normal  degree  of  patencv.  Where 
the  obstruction  depends  merelv  upon  venous  engorgement  or 
cedema,  attention  to  the  ujjper  air  passages,  together  with  in- 
flation of  the  middle  ear  with  air.  will  be  efTective  without 
any  other  measures  directed  to  the  tube.  The  beneficial 
effect  of  inflation  uj)on  the  calibre  of  the  Eustachian  canal 
depends  upon  the  fact  that  when  the  normal  calibre  is  re- 
stored for  a  short  time  by  the  passage  of  a  current  of  air 
which  temporarily  relieves  the  engorgement,  it  graduallv  re- 
tains its  normal  patency.  The  air  douche  drives  the  blood 
out  of  the  distended  venous  channels  and  permits  them  to  re- 
sume their  normal  tone,  in  much  the  same  manner  as  an 
elastic  bandage  relieves  venous  engorgement  of  the  extremi- 
ties. If.  hcnvever,  actual  hvpertrophv  has  taken  place,  stimu- 
lation of  the  mucous  membrane  mav  be  necessarv  in  order  to 
effect  restoration.  This  is  particularly  true  in  instances  in 
which  excessive  secretion  is  present.  The  pharyngeal  orifice 
of  the  tube  is  the  part  first  affected,  and  the  changes  are  most 
marked  in  this  region.  Before  attempting  anv  local  medica- 
tion,  the  mucous  membrane  must  be  thoroughly  cleansed  from 
adherent  secreti(Mi.  otherwise  our  aj)j)licati()n  will  have  but 
little  effect.  Tliis  mav  be  done  by  washing  out  the  jiharvn- 
geal  orifice  of  the  tube  with  an  alkaline  solution,  such  as  a 
weak  solution  of  bicarbonate  of  soda,  or  the  ordinary  Dobell's 
fluid,  or  a  solution  of  boric  acid  of  about  twenty  grains  to 
the  ounce,  to  which  may  be  added  half  a  drachm  of  Listerine. 
This  cleansing  is  effected  by  employing  a  device  which  con- 
sists of  a  Eustachian  catheter  the  extremity  of  which  is  closed, 
while  the  curved  portion  of  the  instrument  is  supplied  with 
lateral  perforations.  Fluid  injected  through  this  instrument 
does  not  enter  the  lumen  of  the  tube,  although  the  trumpet- 
shapjed  orifice  is  thoroughly  washed  and  freed  from  any  tena- 
cious secretion.  The  solution  mav  be  injected  by  means  of 
a  common  ear  svring^e  inserted  into  the  outer  end  of  the  in- 


366  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

strument,  or  the  syringe  may  be  provided  with  a  conical  tip 
which  fits  it  exactly.  The  mouth  of  the  tube  may  also  be 
cleansed  by  wiping  it  out  with  a  pledget  of  cotton,  the  appli- 
cator being  curved  like  the  Eustachian  catheter.  After  thor- 
oughly cleansing  the  pharyngeal  orifice  of  the  tube,  it  should 
be  touched  with  an  astringent  solution.  A  solution  of  nitrate 
of  silver,  ten  to  thirty  grains  to  the  ounce,  is  the  application 
most  used.  In  older  cases  the  application  of  equal  parts  of 
compound  tincture  of  iodine  and  glycerin  is  efficient.  Even 
where  the  tube  is  involved  for  a  considerable  distance  beyond 
its  pharyngeal  aperture,  treatment  of  this  region  may  cause 
absorption  of  the  newly  deposited  tissue.  If  this  fails,  applica- 
tions may  be  made  to  the  entire  length  of  the  canal,  either  by 
means  of  stimulating  vapors  or  of  medicinal  solutions.  The 
precise  manner  of  carrying  out  these  measures  has  already 
been  given.  Dilatation  of  the  Eustachian  canal  by  bougies  is 
exceedingly  efficacious  where  the  deposit  is  of  long  standing, 
the  mechanical  stimulation  due  to  the  presence  of  the  instru- 
ment within  the  lumen  of  the  tube  causing  absorption  of  the 
new-formed  tissue.  If  the  walls  of  the  tube  seem  much  re- 
laxed and  the  obstruction  recurs  quickly,  although  the  tube 
may  admit  the  passage  of  a  bougie  of  considerable  size,  it  is 
well  to  leave  the  instrument  in  position  for  several  minutes  to 
restore  the  normal  tone  of  the  tissues.  Medicated  bougies 
may  be  used,  but  their  emplovment  is  difificult,  and  presents 
no  advantages  over  topical  applications  made  in  the  manner 
described  under  tubal  congestion. 

The  injection  of  fluids  into  the  tube  and  tympanum  is 
never  wise.  It  is  true  that  excellent  results  have  occasional- 
ly been  obtained  by  this  means,  but  the  same  object  may  be 
accomplished  without  subjecting  the  patient  to  the  serious 
possibilities  which  the  injection  of  fluid  into  the  tube  entails. 
Although  the  tympanic  portion  of  the  Eustachian  canal  is 
inclosed  in  firm,  bony  walls,  it  should  always  be  remembered 
that  an  obstruction  may  lie  at  the  tympanic  orifice  of  the 
tube;  and  although  we  can  not  dilate  the  osseous  canal,  we 
may  overcome  an  obstruction  in  the  locality  above  named, 
and  should  never  fail  to  pass  the  instrument  through  the  en- 
tire length  of  the  canal  until  the  tympanic  cavitv  is  entered. 
Relaxation  of  the  mucous  lining  may  occur  even  in  this  re- 
gion, and  topical  applications  may  be  beneficial.  In  many 
instances  an  inspection  of  the  membrana  tympani  will  reveal 


TREAT.MKNT— REMOVAL    OF    FLUID. 


Z^7 


the  bouu^ie  in  the  tympanic  cavitv.  It  usually  lies  behind  and 
a  little  below  the  short  process  of  the  nialleus,  and  bv  pres- 
sure can  be  made  to  push  the  drum  membrane  over  it  out- 
ward into  the  canal. 

The  chantres  within  the  tympanum  may  consist  of  an  ac- 
cumulation of  fluid,  localized  or  diffuse  hypertrophic  chanijes, 
and  adhesions.  When  fluid  is  present,  its  removal  shoultl  be 
effected  throuii^h  the  Eustachian  tube  if  possible.  To  this 
end,  the  operation  of  inflation  should  be  performed  with  the 
head  of  the  patient  inclined  a  little  forward  and  toward  the 
opposite  side  ;  the  current  of  air.  ujion  entering  the  tympanum, 
will  then  force  the  fluid  throui^h  the  Eustachian  tube  into  the 
pharyntreal  vault.  When  this  takes  place,  the  sound  heard 
upon  auscultation  chantj^es  in  character  from  that  character- 
istic of  fluid  within  the  tympanum  to  the  harsh,  bubblin<x 
sounds  which  are  indicative  of  secretion  at  the  pharvno^cal 
orifice  of  the  canal.  Subsequently  auscultation  rcvtals  an 
entire  absence  of  bubblinij  sounds  as  the  air  enters  the  cavity. 
When  removed  in  this  manner,  the  effusion  is  apt  to  accumu- 
late a  second  time.  l"o  prevent  this,  it  is  wise  to  follow  the 
simple  inflation  with  the  introduction  of  a  medicated  vapor 
into  the  middle  ear.  The  vapor  of  compound  tincture  of  ben- 
zoin, of  eucalyptus,  menthol,  alcohol,  ether,  iodine,  or  any 
other  volatile  drug^  which  possesses  mild  stimulatin*.::  j)roj)erties 
may  be  used.  The  lenij^th  of  time  during  which  the  applica- 
tion shall  be  continued  will  depend  upon  the  effect  produced, 
the  dejn^ree  of  irritation  should  not  be  suflRcient  to  amount  to 
actual  pain,  and  the  patient  should  be  conscious  of  but  a  mod- 
erate stiiii^ing  sensation  as  the  current  enters  the  tympanum. 
If  the  fluid  accumulates  a  second  time,  or  if  our  efforts  at 
evacuation  through  the  tube  are  not  successful,  the  membrana 
tvmpani  must  be  incised.  Only  very  g-eneral  rules  can  be 
g^iven  as  to  the  proper  point  of  locating  the  incision,  since  the 
fluid  may  be  encapsulated  in  some  of  the  reduplications  of  the 
lining  membrane.  If  the  entire  cavity  is  filled,  h<nvever.  it  is 
best  to  make  the  incision  in  the  posterior  (juadrant.  dividing 
the  membrane  from  a  point  just  below  the  posterior  fold  to 
the  inferior  pole,  the  line  of  section  running  parallel  to  the 
peripheral  attachment  of  the  membrane.  This  incision  may 
seem  unnecessarily  free,  but  the  results  obtained  are  much 
better  than  where  a  small  opening  is  made,  since  a  large 
opening  permits   complete  evacuation  of  the   fluid,   and  the 


368  CHRONIC    CATARRHAL   OTITIS   MEDIA. 

parts  heal  within  a  few  hours,  with  the  development  of  no 
cicatricial  tissue.  A  small  opening  remains  patent  for  a 
longer  period  and  is  closed  by  a  deposit  of  cicatricial  tissue, 
and  the  tension  of  the  drum  membrane  is  altered. 

After  the  membrana  tympani  has  been  incised  certain  meas- 
ures may  be  necessary  to  cause  the  lining  membrane  of  the 
middle  ear  to  return  to  a  perfectly  normal  condition,  and 
thus  prevent  the  reaccumulation  of  the  fluid.  These  measures 
consist  in  the  instillation  of  astringent  solutions  through  the 
opening  made,  or  their  injection  through  the  Eustachian  tube. 
Tiie  former  method  is  decidedly  preferable,  since  the  results 
obtained  are  equally  good  and  the  discomfort  to  the  patient 
is  much  less.  In  certain  instances  a  small  amount  of  fluid  re- 
mains in  the  cavity  after  the  greater  portion  has  been  ab- 
sorbed; this  remnant  becomes  inspissated  and  adheres  closely 
to  the  lining  membrane  of  the  middle  ear.  Inflation  of  the 
tympanum  fails  to  remove  the  collection  either  on  account 
of  its  viscidity,  or  owing  to  the  fact  that  it  lies  out  of  the 
direct  air  current.  Under  these  conditions  the  tympanum 
should  be  thoroughly  washed  out  with  boiled  water  or  with 
Thiersch's  solution.  This  lavage  ma}'  be  carried  out  either 
through  the  Eustachian  tube  or  through  an  artificial  opening 
in  the  membrana  tympani.  Where  the  object  is  to  cleanse  the 
cavity  rather  than  to  medicate  its  lining  membrane,  irrigation 
through  the  Eustachian  tube  is  preferable,  since  all  the  re- 
cesses of  the  cavity  are  reached  in  this  way  and  a  considera- 
ble quantity  of  fluid  may  be  used  in  irrigation.  In  carrying 
out  this  procedure  the  catheter  should  possess  a  rather  sharp 
curve,  and  the  curved  portion  should  be  somewhat  longer  than 
where  the  instrument  is  used  for  inflation  simplv.  It  should 
be  of  such  size  as  to  permit  its  entrance  into  the  Eustachian 
tube  for  a  considerable  distance.  Very  little  force  should  be 
used  in  injecting  the  fluid  through  the  tube  into  the  middle 
ear.  The  injection  may  be  made  either  with  the  common  syr- 
inge or  with  a  fountain  syringe,  the  reservoir  being  raised  to 
such  a  level  as  to  permit  the  current  to  pass  slowly.  In  this 
way  any  inspissated  material  is  removed  and  the  cavity  thor- 
oughly cleansed.  If  proper  aseptic  precautions  have  been 
observed,  the  wound  in  the  membrana  tympani  closes  within 
thirty-six  hours  and  usually  reaccumulation  does  not  take  place, 
while  the  improvement  in  function  is  frequently  considerable. 
It  must  be  stated  that  although  paracentesis  affords  a  simple 


TRKATMF.NT— TENOTOMY  OF  THE  TENSOR  TYMPANI.  369 

:md  efficient  means  of  disposing  of  fluid  within  tlie  tympanum, 
tfie  collection  is  exceedingly  liable  to  reaccumulate.  When 
this  occurs  in  individuals  bevond  fifty  years  of  age  it  is  un- 
wise to  attempt  any  radical  measures  to  prevent  reaccumula- 
tion  of  fluid.  Incision  of  the  membrana  tympani  in  these  cases 
is  not  painful  and  affords  complete  relief  for  periods  varying 
from  a  few  weeks  to  several  months.  In  advanced  age  the 
reparative  processes  of  the  body  are  decidedly  below  the  nor- 
mal standard,  and  very  slight  causes  easily  excite  a  middle- 
ear  inllammation.  Our  efforts,  therefore,  should  aim  rather 
to  relieve  these  cases  by  successive  operations  than  to  attempt 
{•ermanently  to  cure  the  affection  by  means  which  may  result 
in  a  serious  micidle-ear  inflammation. 

Under  the  impression  that  the  continued  pressure  of  the 
manubrium  mallei  uj)on  the  internal  wall  of  the  middle  ear 
acted  as  an  exciting  cause  of  the  inflammatory  process,  and 
that  the  maintenance  of  the  malleus  in  this  abnormal  position 
was  due  largely  to  shortening  of  the  tensor  tvmj)ani  tendon. 
Weber-Liel  *  advocated  the  operation  of  tenotomy  of  this 
muscle  in  these  cases.  If  we  could  separate  cases  in  which 
the  inflammatory  process  de|)cndcd  entirely  upon  the  spastic 
contraction  of  the  tensor  tympani  muscle  there  is  but  little 
doubt  that  section  of  the  tendon  would  be  followed  by  com- 
plete cure.  Unfortunately,  we  have  no  means  of  recognizing 
the  fact  that  the  process  is  so  limited  in  extent,  and  experi- 
ence teaches  that  by  the  time  the  tendon  is  permanently  short- 
ened other  portions  of  the  middle  ear  have  become  affected. 
The  relief  obtained  by  the  operation  was  demonstrated  by  an 
im])rovcment  in  the  ear  operated  upon  and  also  by  a  decided 
improvement  in  the  organ  of  the  opposite  side,  and  both 
Weber-Liel  and  later  Cholewa  +  have  urged  the  advisability 
of  the  procedure  for  the  purpose  of  preventing  the  extension 
of  disease  to  the  opposite  car.  The  only  fault  that  can  be 
found  with  the  procedure  is  that  it  is  not  radical  enough,  as 
it  corrects  the  increase  in  tension  at  but  one  point  in  the  os- 
sicular chain.  The  tendon  of  the  tensor  tympani  may  be  the 
locality  in  which  the  fibrous  changes  first  manifest  themselves; 
but,  before  this  condition  is  recognized,  a  diffuse  hypertrophic 
process  has  involved  a  large  portion  of  the  membrane  lining 

*  Monatsschr.  fiir  Ohrenheilk..  1868,  Nos.  4  and  I2. 
f  Arch,  of  Otol.,  vol.  xix,  p.  151. 
25 


370 


CHRONIC    CATARRHAL    OTITIS    MEDIA. 


of  the  middle  ear.  It  is  our  duty,  then,  to  attempt  the  correc- 
tion of  this  condition  as  well  as  to  direct  our  measures  toward 
the  contracted  tendon  of  the  tensor. 

In  order  that  the  mucous  membrane  of  the  tympanum  may 
resume  its  normal  condition  after  hypertrophic  changes  have 
once  taken  place,  it  is  necessary  to  increase  temporarily  the 
blood  supply  of  the  part ;  in  other  words,  to  create  artificial- 
ly a  moderately  acute  inflammatory  process.  The  most  con- 
venient method  of  effecting  this  change  is  to  introduce  some 
stimulating  vapor  through  the  Eustachian  tube  into  the  mid- 
dle ear  in  the  manner  described,  at  the  same  time  removing 
all  secondary  causes  which  tend  to  increase  the  congestion  of 
the  tympanic  lining.  Stimulation  by  means  of  fluids  injected 
into  the  cavity  should  not  be  undertaken  unless  an  opening 
has  been  previously  made  in  the  membrana  tympani.  If  in 
any  given  case  it  seems  advisable  to  inject  fluid  into  the  mid- 
dle ear,  care  must  be  taken  that  the  instruments  employed  in 
the  operation,  as  well  as  the  fluid  itself,  have  been  thoroughly 
sterilized  by  heat.  I  am  decidedly  in  favor,  where  it  is  neces- 
sary to  use  fluids  in  this  manner,  to  introduce  them  into  the 
tympanum  through  an  opening  made  in  the  membrana  tvm- 
pani  for  the  purpose. 

The  choice  of  medicated  vapors  in  any  given  case  will 
depend  upon  the  rules  given  for  their  selection  for  a  simi- 
lar condition  of  the  Eustachian  tube  in  acute  cases.  If  it 
seems  wise  to  make  use  of  drugs  in  solution,  we  should  begin 
at  first  with  weak  solutions,  such  as  a  solution  of  zinc  chlo- 
ride, two  grains  to  the  ounce  ;  zinc  sulphate,  ten  grains  to 
the  ounce  ;  or  nitrate  of  silver,  ten  grains  to  the  ounce.  The 
strength  of  the  solution  mav  be  increased  until  the  desired 
effect  is  obtained.  The  fluid  is  introduced  through  the  open- 
ing in  the  membrana  tympani  by  means  of  the  middle-ear 
syringe  (shown  in  Fig.  99),  or  by  the  middle-ear  pipette.  My 
experience  has  been  that  where  the  process  has  advanced  so 
far  that  the  introduction  of  vapors  does  not  produce  the  de- 
sired effect,  no  benefit  is  gained  by  the  injection  of  fluids. 

Passive  motion  for  securing  greater  mobility  in  the  ossic- 
ular chain  by  stretching  the  newly  deposited  tissue  is  not 
indicated  here,  as  when  the  disease  is  in  this  hypertrophic 
stage  it  constitutes  an  active  inflammator}-  process,  which 
may  be  aggravated  by  mechanical  irritation.  The  amount  of 
motion  imparted  to  tlic  ossicles  bv  catheter  inflation  pre'-.ervcs 


TREATMENT— MECHANICAL    SUPPORT.  -.-j 

their  motility  sufficicntlv  without  the  enii)l(^viiient  of  other 
measures  in  this  direction.  Wliere  the  tension  of  the  ossicu- 
hir  chain  is  relaxed,  threat  improvement  sometimes  follows 
the  use  of  an  artificial  support,  as  first  suggested  bv  Blake.* 
This  may  consist  of  a  small  pledget  of  cotton  inserted  in  front 
of  the  short  process  of  the  malleus  so  as  to  press  upon  it. 
crowding  the  ossicle  backward  and  inward,  or  a  narrow  stri]) 
of  thin  rubber  may  be  used,  tiie  ends  of  the  stiip  being 
brought  together  and  grasped  in  the  forceps,  and  carrieti  into 
the  canal  so  that  the  convexity  of  the  f(jld  in  the  strip  of  rub- 
ber rests  against  the  short  process.  Upon  removing  the  for- 
ceps the  ends  of  the  rubber  separate,  impinging  upon  the 
anterior  and  posterior  walls  of  the  canal,  while  the  convex 
surface  of  the  strip  presses  against  the  short  process  of  the 
malleus  and  crowds  the  ossicle  against  the  incus.  Failing  to 
check  the  progress  of  the  disease  by  anv  of  the  above  meas- 
ures, or  in  cases  of  long  standing  in  which  sclerotic  changes 
are  beginning  to  take  place,  as  evidenced  by  marked  retrac- 
tion of  the  mcmbrana  tvnij)ani,  exaggeration  of  the  posterior 
fold,  and  the  presence  of  atroj)hic  areas  in  the  drum  mem- 
brane itself,  resort  must  be  had  to  surgical  measures.  These 
comprise  tenotomy  of  the  tensor  tvmpani,  as  already  men- 
tioned, division  of  an  exaggerated  posterior  fold  (plicotomv). 
section  of  intratvmpanic  adhesions  binding  the  ossicles  to 
each  other  or  to  the  tvnijianic  wall,  or  separation  of  the  drum 
membrane  from  the  internal  wall  of  the  middle  ear,  to  which 
it  may  ha\"e  adhered  :  all  are  of  value  in  sj)ecial  cases.  The 
only  objection  to  them  lies  in  the  fact  that  the  lesion  is  sel- 
dom limited  to  one  particular  region.  The  evidence  of  in- 
creased tension  within  the  conducting  chain  is  unmistakable, 
but  in  almost  all  cases  the  entire  conducting  chain  is  involved, 
and  not  one  particular  portion. 

Where  the  membrana  tympani  alone  is  the  seat  of  the  t)b- 
struction  the  establishment  of  an  opening  through  the  drum 
membrane  is  beneficial.  Its  permanency  was  long  ago  shown 
to  be  the  exception  rather  than  the  rule,  however.  If  the 
membrane  is  relaxed,  its  tension  may  be  corrected  bv  apply- 
ing a  disk  of  thin  paper  over  the  relaxed  area.  If  the  paper 
disk  is  moistened  before  it  is  applied  it  will  maintain  its  posi- 
tion upon  drying.     My  own   practice  has  been,  whcnevei-  im- 


Arch.  of  Otol.,  vol.  xxi,  p.  i66. 


372  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

pairment  of  function  has  seemed  to  depend  entirely  upon  a 
middle-ear  lesion,  and  when  satisfactory  improvement  has  not 
been  obtained  by  the  employment  of  measures  detailed  above, 
.to  remove  the  membrana  tympani,  malleus,  and  incus,  and  to 
divide  subsequently  adhesions  about  the  stapes  and  about  the 
round  window.  The  membrane  may  be  reproduced,  but  the 
septum  thus  formed  is  thin,  comparatively  insensitive,  and 
possesses  but  slight  vitality.  Its  removal  is  easily  effected  a 
second  time,  or  even  a  third  time  if  necessary,  after  which  a 
permanent  opening  usually  remains.  The  chief  value  of  the 
procedure  lies  in  the  fact  that  it  enables  us  to  free  the  stapes 
from  adhesions  which  may  subsequently  develop  and  be  a 
source  of  serious  functional  impairment. 

The  subject  of  surgical  interference  in  these  cases  and  the 
technique  of  the  various  operations  is  considered  in  the  section 
devoted  to  the  operative  surgery  of  the  middle  ear. 

Chronic  Hyperplastic  Otitis  Media. 

iEtiology. — The  hvperplastic  form  of  tympanic  inflamma- 
tion may  develop  from  the  form  described  in  the  preceding 
section ;  rarely  it  follows  a  purulent  otitis  media  ;  it  may  also 
occur  as  an  idiopathic  affection.  The  cases  belonging  to  the 
idiopathic  group  may  follow  a  severe  illness,  physical  or  men- 
tal exhaustion,  and  malnutrition.  They  may  depend  upon 
interference  with  the  trophic  nerve  supply  of  the  middle  ear. 
Sex  exerts  a  certain  influence,  females  being  more  frequently 
attacked  than  males,  from  which  we  assume  that  exposure 
plays  but  little  part  in  the  causation  of  the  affection.  A  se- 
vere mental  shock,  such  as  fright,  may  exert  a  causative  in- 
fluence in  the  disease  under  consideration.  The  influence  ex- 
erted by  any  abnormal  condition  in  the  upper  air  passages  is 
usually  of  but  slight  importance  except  in  those  cases  which 
follow  the  hypertrophic  form  of  inflammation.  The  disease 
mav  attack  both  ears,  or  the  organ  of  but  one  side  may  be 
affected.  When  the  condition  is  present  upon  both  sides  the 
organ  last  affected  may  become  involved  only  after  many 
years,  and  it  frequently  happens  that  patients  do  not  dis- 
cover any  impairment  of  hearing  until  the  previously  healthy 
ear  is  affected,  when  examination  reveals  marked  impair- 
ment in  the  hearing  power  of  the  opposite  side.  The  affec- 
tion is  to  an  extent  hereditary,  especially  in  those  cases  of 
neuropathic  origin,  although  this  factor  in  causation  is  prob- 


TATHOLOGY. 


373 


ably  much  overrated.  Hyperplastic  inflammation  of  the 
middle  ear  is  most  common  between  the  ages  of  forty  and 
fifty,  although  it  may  develop  in  early  adult  life,  or  even  in 
childhood.     Its  development  in  advanced  age  is  rare. 

Pathology. — The  changes  which  the  mucous  membrane 
undergoes  have  already  been  touched  upon.  They  consist 
of  an  increase  of  fibrous  tissue  in  the  mucous  membrane  lin- 
ing the  tvmpanum,  which  becomes  firm  and  dense  in  consist- 
ency and  less  vascular.  The  augmentation  of  the  fibrous  ele- 
ments causes  atrophv  of  the  glandular  structures  and  dimin- 
ished secretion  results.  As  the  tissues  undergo  this  fibrous 
metamorphosis  they  become  dense,  and  the  normal  ligaments 
which  support  the  ossicles  within  the  middle  ear  and  which 
bind  them  to  one  another  are  shortened.  In  addition  to 
these  changes  in  the  lining  membrane,  a  certain  amount  of 
new  tissue  is  deposited,  forming  bands  of  adhesions  between 
the  ossicles  and  the  internal  wall  of  the  tympanum,  displac- 
ing the  ossicular  chain  and  binding  it  firmly  to  the  osseous 
walls  of  the  middle  ear.  The  mcmbrana  tympani  is  usually 
unchanged  in  the  earlv  stages,  but  by  stretching  may  become 
atro])hic  in  places,  or  by  prolonged  contact  with  the  internal 
wall  of  the  tvmpanum  may  become  adherent  to  it.  The 
hyperplastic  changes  are  usually  more  marked  in  the  region  of 
the  oval  or  the  round  window,  in  the  former  position  binding 
the  stapes  firmly  in  the  pelvis  ovalis ;  while  occurring  in  the 
latter  locality  thev  prevent  free  oscillation  of  the  membrana 
tympani  secundaria.  When  the  stapedio-vestibular  ligament 
is  involved,  the  foot  jiiate  bec(Mnes  firmly  fixed  in  the  foramen 
ovale,  and  in  cases  of  long  standing  bony  sclerosis  may  oc- 
cur. The  tendon  of  the  stapedius  muscle  with  the  mucous 
folds  which  commonly  invest  it  undergoes  shortening,  caus- 
ing displacement  and  fixation  of  the  stapes,  the  posterior 
crus  being  drawn  toward  the  adjacent  wall  of  the  oval  niche, 
to  which  it  contracts  adhesions.  All  of  these  changes  about 
the  oval  and  round  windows  may  occur  without  displace- 
ment of  the  membrana  tympani,  or  without  giving  rise  to 
anv  changes  discoverable  upon  ocular  inspection. 

When  the  upper  part  of  the  cavity  is  much  involved,  the 
entire  ossicular  chain  is  frequently  displaced  inward,  dimin- 
ishing the  breadth  of  the  tympanic  cavity  without  rotation  of 
the  ossicles  about  the  axis  band.  In  other  cases  the  fibres 
may  be  so  disposed  as  to  draw  the  tip  of  the  manubrium  in- 


374 


CHRONIC    CATARRHAL    OTITIS    MEDIA. 


ward,  exaggerating  the  anterior  and  posterior  folds  and  giv- 
ing rise  to  a  picture  similar  to  that  seen  when  the  Eustachian 
tube  is  closed,  the  handle  of  the  malleus  lying  almost  hori- 
zontal, the  short  process  being  prominent. 

The  changes  may  involve  the  upper  part  of  the  cavity 
primarily,  and  lead  to  rotation  of  the  malleus  about  its  long 
axis,  increasing  or  diminishing  its  apparent  breadth,  as  ob- 
served in  speculum  examination.  A  process  sclerotic  from 
the  first  does  not  give  rise  to  the  crumpled  appearance  in  the 
membrana  ffaccida  mentioned  in  the  preceding  chapter;  this 
condition,  according  to  Walb,*  is  characteristic  of  a  secon- 
dary sclerosis  following  hypertrophic  changes.  The  same  may 
be  said  in  general  of  most  of  the  changes  recognizable  in 
otoscopic  examination,  marked  displacement  of  the  ossicular 
chain  usually  indicating  a  preceding  hypertrophic  process. 

The  inflammatory  process  is  not  limited  to  connective 
tissue  alone,  but  may  involve  the  osseous  structures  as  well. 
When  this  occurs  the  shaft  of  the  malleus  may  present  irreg- 
ularities due  to  localized  periostitis. 

Labyrinthine  involvement  of  various  grades  may  occur 
even  in  the  early  stages.  It  may  be  so  slight  as  to  escape 
notice  or  in  advanced  cases  so  extensive  as  to  play  an  impor- 
tant part  in  the  impairment  and  perversion  of  the  function. 
When  both  ears  are  affected  the  labyrinthine  involvement  is 
frequently  more  marked  upon  the  side  last  involved. 

The  changes  occurring  in  the  Eustachian  tube  result  in  an 
undue  patency  of  the  canal ;  this  condition  exposes  the  parts 
within  the  tympanum  to  traumatism  from  violent  efforts  at 
coughing,  sneezing,  or  clearing  the  nose.  The  tubal  muscles 
are  also  involved,  becoming  atrophic  quite  early  in  the  course 
of  the  disease. 

Symptomatology.  —  In  the  early  stages  the  affection  is  so 
insidious  that  considerable  damage  occurs  before  the  atten- 
tion of  the  patient  is  directed  to  the  ears.  Subjective  noises 
are  present  in  a  large  number  of  instances,  and  often  cause 
more  distress  than  the  impairment  of  hearing.  They  appear 
early  in  the  affection,  as  a  rule,  and  increase  in  severity  as 
the  disease  progresses.  Slight  attacks  of  giddiness  may  also 
occur  in  the  early  stages,  but  are  usually  attributed  by  the 
patient  to  a  disturbance  of  digestion  or  to  some  irregularity  in 


*  Schwartze,  Handb.  der  Ohrenheilk.,  Leipzig,  1S93,  vol.  ii,  p.  198. 


SYMPTOMATOLOGY.  3^5 

the  habit  of  life.  The  impairment  in  hearing  is  at  first  mod- 
erate, and  its  advance  is  so  gradual  as  not  to  be  noticed  by 
the  patient  until  both  organs  are  involved,  or  until  one  is  se- 
riouslv  affected.  I'ain  ot  neuralgic  type  and  intermittent  in 
character  is  occasionally  present  in  these  cases.  The  attacks 
of  pain  are  usually  of  but  short  duration,  the  patient  com- 
plaining that  several  times  during  the  day  there  has  been  a  sud- 
den sharp  pain  in  the  throat  radiating  toward  the  ear.  Occa- 
sionally a  dull  headache  referred  to  the  orbital  region  of  one 
or  both  sides  is  complained  of.  This  is  apt  to  persist  for  a 
considerable  length  of  time,  and  the  patient  feels  entirely  un- 
fitted for  any  kind  of  mental  or  physical  labor,  the  entire  sen- 
sorium  being  to  an  extent  blunted.  This  dull  mental  condi- 
tion causes  considerable  dej)ression.  which  in  turn  aggravates 
both  the  impairment  in  function  and  the  distress  caused  by 
the  tinnitus.  As  the  result  of  this  impairment  of  the  general 
nervous  tone,  the  condition  of  the  jiatient  may  approach  that 
seen  in  melancholia,  and  in  certain  instances  the  patient  may 
develop  a  suicidal  mania  and  attemj)t  to  take  his  own  life 
rather  than  bear  the  distress  which  the  tinnitus  occasions. 
The  perverted  mental  condition  affects  the  general  nutrition 
of  the  body,  and  the  patient  loses  flesh,  becomes  ana-mic. 
and  to  all  appearances  is  suffering  from  some  severe  con- 
stitutional malady,  producing  pronouncetl  neurasthenic  s\iiip- 
toms. 

In  the  more  advanced  stages  the  impairment  of  hearing  is 
of  a  somewhat  j)eculiar  type,  in  that  it  undergoes  maikcd 
changes  from  no  other  assignable  cause  than  the  effort  made 
by  the  patient  to  understand  conversation.  When  attention 
is  not  particularly  drawn  to  the  fact  that  the  power  of  audi- 
tion is  being  tested,  the  hearing  may  be  fairly  good  ;  the 
moment,  however,  the  patient  is  conscious  that  a  test  is  be- 
ing made  of  his  ability  to  hear  certain  sounds,  the  impair- 
ment increases  to  a  marked  degree,  and  words  which  a  few 
moments  before  have  been  understood  perfectly  well  are  not 
heard.  The  facies  whfch  these  patients  present  is  somewhat 
characteristic,  being  indicative  of  intense  mental  strain,  due 
probably  to  their  efforts  to  conceal  their  affliction. 

It  must  be  admitted  also  that  the  constant  effort  to  hear 
which  these  patients  exert  is  responsible  for  the  condition  of 
impaired  nervous  tone  from  which  they  suffer.  The  fatigue 
of  the  higher  centres  from  this  constant  strain  can   not  fail 


376  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

to  exert  a  profound  influence  upon  the  nerve  elements  and 
lead  to  nerve  exhaustion. 

A  curious  mental  perversion  which  many  exhibit,  in  addi- 
tion to  the  depression  of  spirits  already  spoken  of,  is  the  feeling 
of  suspicion  with  which  they  regard  even  their  most  intimate 
acquaintances.  As  they  can  not  understand  general  conver- 
sation, the  patients  in  whom  the  neurotic  tendency  is  pro- 
nounced seem  to  feel  that  any  remark  made  in  a  low  tone 
refers  to  their  condition  and  is  a  direct  reflection  upon  them. 
For  this  reason  many  become  averse  to  performing  their 
social  duties  and  isolate  themselves  as  completel}'  as  possible. 
It  is  hardly  necessary  to  state  that  this  action  tends  rather  to 
increase  than  to  relieve  the  functional  impairment. 

After  the  disease  has  persisted  for  a  long  time  the  tinnitus, 
which  was  at  first  distressing,  may  become  less  marked,  or 
may  disappear  completely.  When  both  ears  are  involved,  the 
tinnitus  is  often  more  severe  upon  the  side  last  affected.  This 
is  undoubtedly  due  to  the  fact  that  labyrinthine  changes  upon 
the  side  primarily  affected  have  gone  on  to  such  a  degree 
that  the  portion  of  the  labyrinth  which  normally  responds 
to  sounds  similar  in  character  to  the  tinnitus  from  which  they 
formerly  suffered  has  been  completely  exhausted,  and  no 
longer  reacts  to  stimulation  due  to  increased  pressure. 

Diagnosis. — A.  Physical. — These  cases  present,  upon  ex- 
amination, appearances  which  vary  widely,  according  to  the 
course  which  the  affection  has  pursued.  When  the  process 
has  been  sclerotic  from  the  first,  the  ear  may  present  no 
changes  upon  inspection.  The  position  of  the  light  reflex 
may  be  normal ;  the  lustre  of  the  membrane  may  be  pre- 
served ;  the  density  may  be  uniform,  and  no  deviation  from 
the  normal  position  may  be  recognizable.  Under  these  con- 
ditions we  are  usually  correct  in  assuming  that  the  process 
has  been  of  the  hyperplastic  type  from  its  incipiency,  and 
that  the  deposit  of  fibrous  tissue  has  taken  place  chiefly  about 
the  oval  and  round  windows.  Occasionally  inspection  of  the 
inner  extremity  of  the  osseous  meatus  will  reveal  a  slight 
change  in  color,  the  cutis  being  of  a  somewhat  pinkish  tinge. 
This  is  indicative  of  the  presence  of  an  inflammatory  process 
within  the  tympanic  cavity,  and  shows'  that  the  disease  is  still 
in  an  active  stage.  Where  the  membrana  tympani  has  be- 
come slightly  atrophic  we  may  observe  a  similar  congestion 
affecting  the  inner  tympanic  wall,  which  imparts  a  slightly 


DIAGNOSIS— PHYSICAL    EXAMINATION. 


7 


pinkish  tin2:e  to  the  otherwise  normal  membrana  tympani. 
The  thinnini;  of  tlie  membrana,  particularly  of  the  upper  and 
posterior  segment,  may  enable  us  to  see  the  long  process  of 
the  incus,  the  incudo-stapedial  articulation,  and  stapedius 
tendon  in  their  normal  position  (Fig.  95).  In  other  instances 
we  may  have  slight  sinking  inward  ot  the  membrana  tym- 
pani, with  rotation  of  the  malleus  about  its  long  axis.  If 
rotation  has  occurred  from  behind  forward,  the  shaft  of  the 
malleus  appears  somewhat  broader  than  normal,  and  of  a 
dead-white  color  (Fig.  102).  This  change  in  color  is  tlue  to 
atrophic  changes  in  the  overlying  fibrous  laver.  When  ro- 
tation takes  place  in  the  opposite  direction  we  usually  have 
considerable  retractit)n  of  the  membrana  tymj)ani,  exaggera- 
tion of  the  anterior  and  posterior  folds,  and  the  fundus  of 
the  canal  assumes  a  more  circular  contour  (Fig.  104).  In 
these  cases  a  sharp  edge  of  the  prismatic  shaft  of  the  manu- 
brium is  presented  to  view,  which  causes  the  shaft  to  appear 
narrower  than  normal.  In  cases  of  long  standing,  especially 
if  met  with  in  advanced  life,  the  iiiHam- 
matory  process  mav  have  induced  certain 
changes  in  the  periosteal  covering  of  the 
manubrium  mallei,  as  the  result  ol  which 
irregularities    in   outline    appear    iii)on    the 

shaft.     These  are  really  calcihc  dej)osits  in 

,  .  .  ,  .   '  ,  »i  1       •■'<••  104.— Moderate 

this  periosteal  covering,  and  are  worthy  ol         retraction    of    the 

note,  as  thev  siii:gest  the  possibility  of  simi-        *'™'"\.   membrane 

'  .      '         .         .  and  slight  narrow- 

lar  deposits  within   the  tympanic  cavity   in         i„g  of  the  malleus 

the  nei'diborhood  of  the  oval  or  round  win-        '^.^"'"'-"  ^'^^"^  '^^'^- 

■^  lion. 

(low.  Where  the  degree  of  depression  of  the 
drum  membrane  is  considerable  the  process  has  usually  super- 
vened upon  preceding  hypertrophic  changes.  The  increased 
tension  to  which  the  membrana  tympani  has  been  subjected 
has  resulted  in  an  attenuation  of  its  fibrous  layer,  and  inspec- 
tion of  the  underlying  intratympanic  parts  is  possible.  In  ad- 
dition to  these  changes,  it  is  not  uncommon  to  find  the  drum 
membrane  adherent  in  places  to  the  inner  wall  of  the  tym- 
panum, particularly  at  the  umbo.  The  position  of  the  light 
reflex  varies  with  the  degree  of  inclination  of  the  membrana 
to  the  walls  of  the  canal,  but  is  of  little  diagnostic  impor- 
tance. As  mentioned  before,  changes  in  the  membrana  flac- 
cida  are  of  diagnostic  importance  in  determining  the  devel- 
opment of  disease   upon  a  preceding  hypertrophic  process. 


3/8 


CHRONIC    CATARRHAL    OTITIS    MEDIA. 


When  this  has  occurred,  the  membrana  flaccida  presents  a 
crumpled  appearance,  and  may  be  adherent  to  the  neck  of 
the  malleus.  In  cases  that  have  been  hyperplastic  from  the 
start  Shrapnell's  membrane  presents  no  such  changes,  but 
preserves  its  normal  conformation,  although  its  color  may  be 
slightly  lighter  than  in  health.  Deposits  of  lime  salts  in  the 
membrana  tympani  are  seldom  seen,  although,  when  the  con- 
dition is  met  with  in  advanced  life,  such  deposit  may  be  pres- 
ent along  the  annulus  tympanicus. 

B.  Functional  Examination. — The  hearing  power  is  dimin- 
ished to  a  varying  degree  for  both  whispered  and  spoken 
words.  The  degree  of  impairment  for  sharp  noises,  such  as 
the  tick  of  a  watch  or  the  sound  of  an  acoumeter,  varies  with 
the  amount  of  labyrinthine  involvement  present,  and  hence 
constitutes  an  imsafe  test  for  estimating  the  power  of  audi- 
tion when  the  case  first  comes  under  examination,  or  sub- 
sequently for  dcterminati(on  of  the  improvement  which  has 
followed  as  the  result  of  treatment.  Quite  frequently  the 
hearing  power  for  the  watch  and  the  voice  will  be  dispropor- 
tionate. The  watch  mav  not  be  heard  at  all,  while  spoken 
or  whispered  words  mav  be  heard  for  a  considerable  distance, 
and  the  patient  may  consider  this  ear  better  than  its  fellow, 
although  upon  the  opposite  side  the  watch  mav  be  heard  at  a 
considerable  distance,  while  the  voice  can  not  be  understood 
as  well  as  on  the  other  side.  This  depends  upon  the  fact 
that  the  labyrinthine  changes  impair  the  hearing  for  sharp 
sounds,  such  as  the  tick  of  a  watch,  since  these  lie  in  the  up- 
per portion  of  the  musical  scale,  while  that  portion  of  the 
musical  register  which  is  made  use  of  in  conversation  lies  in 
the  lower  portion  of  the  scale,  and  may  be  perceived,  al- 
though considerable  labyrinthine  involvement  is  present.  In- 
terference with  the  conducting  mechanism,  on  the  other  hand, 
impairs  the  hearing  first  for  the  lower  notes,  and  hence  con- 
versation is  heard  more  poorly  in  the  ear  possessing  the  most 
marked  tympanic  involvement. 

The  lower  tone  limit  is  considerablv  elevated.  Bone  con- 
duction is  increased  where  the  changes  are  confined  to  the 
middle  ear.  The  fork  placed  upon  the  vertex  is  referred  to 
the  poorer  ear  provided  only  middle-ear  changes  have  taken 
place,  but  where  serious  labvrinthine  changes  have  occurred 
it  may  be  referred  to  the  better  ear.  This  is  not  invariable, 
however,  for,  as  alreadv  stated  in  pathology,  changes  in  the 


DIAGNOSIS— FUNCTIONAL    EXAMINATION.  370 

perceptive  apparatus  in  the  ear  last  involved  often  progress 
with  great  rapidity,  becoming  in  a  short  time  more  extensive 
than  in  the  organ  first  affected.  When  this  is  the  case  the 
vibrating  tuning  fork  applied  over  the  median  line  of  the  skull 
may  be  referred  to  the  car  which  was  first  affected,  although 
this  may  be  the  poorer  ear.  This  should  not  mislead  the  ex- 
aminer into  believing  that  the  trouble  upon  the  side  to  which 
the  fork  lateralized  is  entirely  free  from  labvrinthine  trouble. 
Increased  tension  in  the  conducting  svstcm  niav  be  sufficient 
to  f)roduce  this  phenomenon,  even  when  the  labvrinth  is  in- 
volved to  a  considerable  extent.  Abs(jlute  bone  conduction 
may  vary  according  to  the  age  of  the  patient  as  well  as  with 
the  degree  to  which  the  labyrinth  has  suffered  ;  hence  this 
test  yields  but  little  information.  When  absolute  bone  con- 
duction is  exaggerated  we  are  justified  in  assuming  that  no 
serious  labyrinthine  involvement  exists.  In  cases  occurring 
in  advanced  life,  however,  the  labvrinth  mav  be  intact,  al- 
though sound  conduction  through  the  cranial  bones  is  below 
normal. 

(^f  much  more  value  than  absolute  bone  conduction  is  the 
relative  duration  of  sound  perception  through  the  solid  media 
as  compared  with  the  period  during  which  the  same  sound  is 
heard  through  the  air.  In  this  manner  we  are  able  to  esti- 
mate with  considerable  certainty  the  amount  of  impairment 
depending  upon  the  labvrinthine  changes,  as  distinguished 
from  that  caused  bv  the  intratvmpanic  lesion.  In  a  given 
case,  where  whispered  words  are  but  poorly  perceived,  if  the 
reversal  of  the  relation  between  air  and  bone  conduction  ex- 
ists for  a  fork  making  512  V.  S.  (double)  or  for  a  fork  of  the 
next  higher  octave,  we  are  warranted  in  assuming  that  most 
of  the  impairment  depends  upon  intralvnijianic  changes. 
With  the  same  degree  of  functional  inifjairmcnt,  if  this  re- 
versal should  occur  onlv  for  a  fork  making  64  \''.  S.,  while 
for  the  octave  above  this  the  air  conduction  was  better  than 
bone  conduction,  we  should,  assume  that  serious  labvrinthine 
changes  had  taken  place. 

The  determination  of  the  upper  tone  limit  is  of  great  value 
in  these  cases  in  confirming  the  fact  that  the  labvrinth  is  in- 
volved. The  first  turn  of  the  cochlea  perceives  the  highest 
notes  of  the  musical  scale,  and  secondary  labvrinthine  degen- 
eration should  be  characterized  bv  a  lowering  of  the  upper 
tone  limit,  as  this  portion  of  the  cochlea  is  in  the  most  imme- 


38o  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

diate  relation  to  the  middle  ear  and  is  the  part  which  suffers 
first  in  secondary  labyrinthine  affection.  When  functional 
examination  shows  a  defect  at  the  upper  portion  of  the  scale, 
persisting  after  anomalous  tension  has  been  corrected  by  in- 
flation, labyrinthine  involvement  is  almost  certain.  A  history 
of  attacks  of  vertigo  is  confirmatory  of  this  opinion. 

Prognosis. — Hyperplastic  changes  within  the  tympanum 
constitute  an  affection  of  the  gravest  character  as  regards  the 
integrity  of  function,  and  one  which  is  less  amenable  to  treat- 
ment than  all  other  aural  diseases.  The  usual  course  is  stead- 
ily progressive,  although  the  affection  may  remain  quiescent 
for  a  long  period  of  years. 

Knowinof  this  fact,  it  is  difficult  to  estimate  the  value  of 
treatment  in  any  given  case,  the  apparent  improvement  being 
possibly  due  to  a  period  of  spontaneous  quiescence.  When 
seen  in  the  early  stages,  and  affecting  but  one  side,  a  fairly 
favorable  prognosis  may  be  given.  When  both  organs  are 
affected  it  will  be  impossible  to  restore  either  ear  to  a  perfect 
condition.  The  most  we  can  hope  for  is  a  slight  improve- 
ment in  one  or  both,  and  to  check  permanently  the  progress 
of  the  affection.  Aside  from  treatment,  the  environment  of' 
the  patient  or  the  occurrence  of  any  severe  illness  affect  the 
progress  of  the  aural  condition  to  a  marked  extent.  A  severe 
illness,  prolonged  physical  exertion,  overwork,  or  anxiety — all 
tend  to  hasten  its  advance.  From  the  fact  that  many  cases 
are  of  neuropathic  origin,  particular  attention  must  be  paid 
to  the  habit  of  life.  All  excesses,  either  of  the  table  or  un- 
due indulgence  in  tobacco  or  alcohol,  should  be  avoided,  and 
the  preservation  of  a  normal  condition  of  the  larger  viscera 
and  of  the  primse  vias  must  be  insisted  upon.  Climate  is  a  factor 
in  prognosis  only  to  the  extent  to  which  it  causes  impairment 
of  the  general  health.  Since  a  drv  atmosphere  and  an  equa- 
ble temperature  are  most  conducive  to  a  normal  condition  of 
the  upper  air  tract,  the  disease  perhaps  progresses  less  rapid- 
ly in  regions  where  these  climatic  conditions  are  found.  I 
am  inclined  to  believe,  however,  that  the  influence  of  climate 
has  been  much  overestimated.  The  age  at  which  the  affec- 
tion  develops  may  influence  its  progress.  When  occurring 
late  in  life,  its  advance  is  usually  slow  unless  aggravated 
by  some  cause,  such  as  a  severe  mtercurrent  disease,  mental 
strain,  or  prolonged  physical  exertion.  Its  appearance  at  the 
menopause  is  not  uncommon,  and  our  prognosis  in  incij^ient 


TREATMENT— PASSIVE    MOTION. 


381 


cases  met  with  at  this  period  of  life  should  be  exceedingly 
i^iiarded. 

Treatment. — The  two  conditions  with  which  we  have  to 
deal  are  those  resulting  from  the  connective-tissue  deposit 
within  the  tvmpanum  and  the  secondary  labvrinthine  changes. 
The  intratvmpanic  condition  being  one  essentiallv  of  rigiditv 
*of  the  ossicular  chain,  our  first  efforts  are  t(^  relieve  this  ab- 
normal tension.  When  seen  early  it  may  be  possible  to  eflect 
absorption  of  the  newly  deposited  tissue  bv  stimulation  of 
the  mucous  lining  of  the  tvm|)anum  ;  this  is  done  bv  inflation 
by  means  of  the  catheter,  making  use  of  some  of  the  stimulat- 
ing vapors  already  mentioned  in  the  treatment  of  hvpertro- 
phic  inflammation.  By  inflating  with  considerable  force  we 
niav  be  able  to  rujiture  recent  adhesions  and  thus  relieve  the 
conducting  mechanism,  or  the  bands  mav  be  stretched  suffi- 
ciently to  permit  increased  mobilitv  in  the  ossicular  chain. 
The  Eustachian  tube  seldom  requires  attention,  although  the 
e.xercise  of  the  tubal  muscles,  either  bv  gargling  of  or  better 
by  massage  bv  means  of  the  luistachian  bougie,  may  correct 
the  changes  which  have  taken  j)Iace  here.  This  massage  also 
exerts  a  favorable  influence 
uj)on  the  tensor  tymj)ani 
muscle  and  prevents  its 
atrophv  and  subsequent 
shortening.  To  massage 
the  tube  in  this  wav  the 
bougie  is  introduced  as  far 
as  the  isthmus  and  then 
moved  rapid h-  inward  and 
outward  for  a  few  seconds. 
I'assive  motion  bv  means 
of  Siegel's  otoscope  affords 
us  a  means  of  combating 
the  adhesions.  The  instru- 
ment should  be  introduced 
int<^  the  meatus,  care  being 
taken  that  it  fits  the  lumen 
air-tight.  The  air  is  then 
alternatelv      rarefied      and 

condensed  in  the  external  auditorv  canal,  imparting  to-and- 
fro  movements  to  the  drum  membrane  and  attached  os- 
sicula.     The  masseur  of  Delstanche  (Fig.  105)  acts  upon   the 


Fig.   io^. — Delstanchc's  masseur. 


382  CHRONIC    CATARRHAL    OTITIS    MEDIA. 

same  principle.  Cases  have  been  reported  where  rupture 
of  the  membrane  has  taken  place  by  the  violent  use  of  these 
instruments  ;  this  seems  hardlv  probable,  however,  if  even 
an  ordinary  amount  of  care  is  taken  in  their  manipula- 
tion. In  the  same  direction  manij)ulati()n  of  the  parts  at  the 
hands  of  the  patient  has  been  tried,  in  some  cases  with  suc- 
cess. The  method  was  first  devised  bv  Homell  and  consists 
in  pressing-  the  tragus  backward  over  the  external  meatus 
until  this  is  completely  closed,  thus  condensing  the  air  in  the 
canal.  Bv  now  alternately  increasing  and  relaxing  the  press- 
ure upon  the  tragus  the  density  of  the  air  in  the  canal  is 
augmented  or  reduced  and  the  drum  membrane  made  to 
perform  inward  and  outward  excursions. 

Politzer  has  devised  a  method  for  maintaining  a  constant 
negative  pressure  in  the  meatus  bv  the  use  of  a  conical  plug 
of  cotton  which  is  impregnated  with  cocoa  butter.  This  plug 
is  inserted  into  the  canal  at  nisjht,  and,  in  virtue  of  its  oleagrin- 
ous  composition,  absorbs  the  air  contained  within  the  meatus, 
thus  causing  the  membrana  tympani  to  move  outward  under 
the  action  of  the  air  within  the  middle  ear.  I  have  had  no  per- 
sonal experience  with  this  plan,  but  in  cases  where  it  has  been 
tried  I  have  failed  to  see  any  benefit.  It  is  certainly  inferior 
either  to  Homell's  method  or  to  systematic  manipulation  with 
the  Siegel  otoscope. 

Lucae  *  has  met  with  considerable  success  in  applying  pas- 
sive motion  to  the  ossicular  chain  by  means  of  the  pressure 
sound.  The  device  consists  of  a  small  tube  through  which  a 
rod  terminating  in  a  cuplike  extremity  passes.  The  other 
end  of  the  rod  lies  within  the  tube  and  rests  upon  a  small  spiral 
spring  the  tension  of  which  is  regulated  bv  a  small  screw  on 
the  handle  of  the  instrument.  In  use,  the  cup-shaped  extrem- 
ity is  applied  to  the  short  process  of  the  malleus,  over  which 
it  fits,  the  manipulation  being  effected  under  illumination. 
Pressure  inward  upon  the  handle  of  the  instrument  is  com- 
municated to  the  ossicular  chain,  the  degree  of  pressure  de- 
pending upon  the  tension  of  the  spring.  By  pressing  the  han- 
dle of  the  instrument  inward  and  then  relaxing  the  pressure, 
the  entire  ossicular  chain  is  alternately  forced  inward  and  then 
allowed  to  resume  its  former  position  through  its  own  elas- 
ticity.    It  has  been  demonstrated  that  pressure  exerted  at  the 


Arch,  fur  Ohrenheilk.,  vol.  xxi,  p.  84. 


TREATMKNT-MASSAGE— OPERATK^X.  383 

short  process  of  the  malleus  is  communicaled  dirt'ctlv  through 
the  incus  to  the  foot  j)late  of  the  stapes,  and  from  this  to  the 
labyrinth.  The  advantage  of  the  device  over  an  ordinary 
probe  consists  in  afTording  us  the  means  of  alternately  increas- 
ing and  diminishing  this  tension  without  removing  the  instru- 
ment from  the  short  pn^ccss  of  the  malleus,  as  its  continual  rc- 
application  would  be  attended  bv  considerable  pain.  In  tiiy 
practice  a  modified  manipulation  similar  to  this  has  not  been 
attended  by  favorable  results. 

The  use  of  the  instrument  of  Lucac  is  somewhat  painlul. 
.Many  patients,  especially  in  juivate  jtractice.  would  object  to 
the  measure,  and  it  has  never  seemed  that  the  results  ob- 
tained warranted  the  infliction  of  so  much  discomfort.  The 
length  of  time  during  which  this  method  ot  treatment  should 
be  carried  on  must  vary  with  the  individual  cases. 

It  has  never  seemed  wise  to  me  to  give  an  absolutely  un- 
favorable prognosis  in  any  case  where  the  lesion  was  confined 
mostly  to  the  middle  ear  without  trying  the  effect  of  stimula- 
tion ol  the  lining  membrane  by  means  of  vapors  for  a  period 
of  four  to  six  weeks,  the  inflation  being  performed  at  first  on 
alternate  days  and  the  interval  gradually  increased  to  three 
or  four  days.  In  addition  to  the  inflation,  j)assive  motion  by 
means  of  the  Siegel  otoscope  may  be  em})l()yed,  or,  il  it  seems 
desirable,  the  use  of  the  pressure  sound.  At  the  end  of  this 
period,  if  no  improvement  results,  surgical  measures  are  im- 
perative, and,  unless  the  degree  of  imj)royement  is  considera- 
ble, the  same  advice  should  be  given.  During  this  period 
the  observance  of  the  ordinary  hygienic  rules  should  be  in- 
sisted upon;  but  attention  to  the  u})perair  passages  is  seldom 
followed  by  marked  imj)royement,  unless  there  have  been 
symptoms  referable  to  these  j)arts  demanding  treatment  for 
their  relief. 

The  surgical  measures  to  be  adopted  in  these  cases  will  de- 
pend upon  the  |)hysical  condition  j)resent.  It  may  be  suffi- 
cient to  divide  tense  bands  which  may  be  seen  by  ocular  in- 
spection, such  as  an  excessive  deposit  of  connective  tissue  in 
the  posterior  fold,  or  adhesions  between  the  tij)  of  the  manu- 
brium and  the  internal  tymj)anic  wall.  As  mentioned  in  a  pre- 
ceding chapter,  however,  it  is  impossible  to  assert  that  the 
increase  in  tension  is  due  to  the  presence  of  adhesions  in  any 
one  particular  locality.  The  procedure,  therefore,  which 
seems  most  wise  is  at  first  an  exploratory  myringotomy  un- 


384 


CHRONIC    CATARRHAL    OTITIS    MEDIA. 


der  strict  antiseptic  or  aseptic  precautions.  A  large  flap  in- 
volving the  entire  postero-superior  segment  of  the  membrana 
vibrans  should  be  turned  downward  and  forward,  the  intra- 
tympanic  structures  inspected,  and  the  degree  of  mobility  of 
the  stapes  determined  bv  means  of  a  delicate  probe  introduced 
through  the  opening.  This  procedure  can  be  conducted  un- 
der cocaine  anaesthesia  and  tests  can  be  made  of  the  hearing 
at  various  stages  of  the  operation.  Occasionally  the  artificial 
opening  into  the  tympanum  may  improve  the  hearing  power 
to  a  remarkable  degree;  if  this  does  not  occur,  disarticulation 
at  the  incudo-stapcdial  joint  should  be  the  next  step.  If  the 
stapes  is  movable,  the  hearing  will  now  be  improved  ;  if  this 
ossicle  is  fixed,  however,  but  slight  improvement  will  be  no- 
ticed. The  stapes  must  then  be  freed  by  division  of  the  sta- 
pedius tendon  and  of  any  adhesions  lying  in  the  oval  niche,  in 
the  manner  to  be  described  in  the  chapter  on  operative  pro- 
cedures within  the  tympanum.  After  the  adhesions  have  been 
severed  as  completelv  as  possible  passive  motion  should  be 
employed,  the  stapes  being  crowded  first  upward,  then  down- 
ward, then  forward,  and  finally  backward  by  means  of  a  deli- 
cate steel  probe  the  extrcmitv  of  which  is  protected  with  a 
small  cotton  pledget  firmly  wound  upon  it.  The  condition  of 
the  round  window  should  also  be  investigated  and  adhesions 
in  this  region  severed  with  an  angular  knife.  If  the  degree  of 
fixation  is  extreme  it  may  be  wise  to  attempt  extraction  of  the 
stapes,  although  the  results  obtained  are  not  perfectly  satisfac- 
tory, and  the  author  prefers  to  remove  the  malleus,  incus,  and 
drum  membrane,  leaving  the  stapes  in  an  easily  accessible  po- 
sition, so  that  subsequently  mechanical  mobilization  may  be 
effected  if  fixation  occurs  again  at  anv  future  time.  I  am 
aware  that  this  method  has  been  criticised,  but  it  possesses 
the  advantage  of  freely  exposing  the  parts  and  enabling  us  to 
make  successive  efforts  at  freeing  the  stapes  rather  than  ne- 
cessitating the  completion  of  all  operative  interference  at  the 
time  of  the  first  operation.  Certainly  in  mv  own  practice  re- 
sults have  been  better  where  this  plan  has  been  followed  than 
where  stapedectomy  has  been  performed,  and  the  opening  in 
the  drum  membrane  closed  as  quickly  as  possible.  The  op- 
erative technique  and  the  results  obtained  will  be  detailed  in 
a  later  chapter,  devoted  to  the  subject  of  middle-car  opera- 
tions. 

The  measures  herein  enumerated  constitute  tiic  most  effi- 


TRKATMENT— INTKRNAL    MEDICATION. 


385 


cicnt  means  at  our  disposal  for  dealing  with  the  intratym- 
panic  conditions.  When  the  labyrinth  is  involved  to  any 
extent  operative  interference  is  contraindicated,  since  the 
cases  do  not  improve  after  such  procedures,  but  are  frequently 
rendered  worse.  The  extent  of  labyrinthine  involvement  in 
any  given  case  is  determined  bv  the  degree  to  which  the 
upper  tone  limit  is  lowered  and  bv  discovering  the  upper 
limit  in  the  musical  scale  at  which  the  normal  ratio  between 
air  and  bone  conduction  is  reversed.  With  a  marked  lower- 
ing of  the  ui)[)er  tone  limit  and  an  inversion  of  the  ratio  be- 
tween bone  and  air  conduction  lor  the  low  notes  alone,  in 
cases  where  the  impairment  of  hearing  is  so  marked  that 
whispered  words  can  not  be  distinguished  at  a  distance  of 
two  or  three  feet  from  the  ear,  the  labyrinthine  feature  is  so 
pnjminent  as  to  positively  contraindicate  operative  interfer- 
ence upon  the  tympanum.  The  result  of  treatment  for  the 
labyrinthine  affection  is  usually  less  favorable  than  in  primary 
labyrinthine  disease.  At  the  same  time,  we  are  at  least  justi- 
fied in  making  the  attem|)t  to  remove  the  ditlicultv. 

The  drug,  the  administration  of  which  is  followed  bv  the 
best  results,  is  undoubtedly  [)ilocari)ine.  The  jjhvsiological 
action  of  the  drug  increases  the  vascularity  of  the  labyrin- 
thine tissues,  at  the  same  time  augmenting  the  activity  oi  the 
cutaneous  and  salivary  glands.  From  the  increased  blood 
supply  any  excess  of  labyrinthine  fluid  is  abstracted  from  the 
bony  cavity  which  contains  it,  entering  the  general  circula- 
tion and  subsequently  being  eliminated  in  the  cutaneous  or 
salivary  secretions.  The  increased  vascularity  may  also  cause 
the  resorption  of  newly  deposited  tissue,  provided  the  deposit 
is  not  too  old.  Formerly  the  drug  was  administered  by 
hypodermic  injection.  This,  however,  renders  it  necessary 
for  the  patient  to  give  up  a  considerable  portion  of  each  day 
to  the  treatment,  and  in  many  instances  this  can  not  be  done. 
For  the  last  two  years  1  have  administered  it  by  the  mouth, 
beginning  at  first  with  doses  of  one  eighth  to  one  sixth  of  a 
grain  two  or  three  times  daily,  the  amount  being  gradually 
increased  until  a  moderate  jihvsiological  effect  followed  each 
exhibition.  It  is  only  necessary  to  warn  the  patient  to  exer- 
cise caution  against  exposure  to  draughts  for  the  period  of 
an  hour  and  a  half  following  each  administration  of  the  rem- 
edy. In  those  cases  where  the  vocation  of  the  patient  neces- 
sitates absence  from  home  for  the  entire  day  one  dose  may 
26 


386  CHRONIC   CATARRHAL   OTITIS   MEDIA. 

be  administered  early  in  the  morning  immediately  upon  risings 
while  the  second  may  be  given  upon  retiring  at  night.  In 
this  way  the  patient  is  able  to  protect  himself  sufficiently 
against  undue  exposure,  and  by  following  this  plan  no  un- 
toward symptoms  have  resulted.  Profuse  salivation  need  not 
be  produced,  nor  need  the  cutaneous  secretion  be  increased 
to  such  a  degree  as  to  be  unpleasant.  A  moderate  increase 
in  the  moisture  of  the  skin  and  in  the  amount  of  saliva  is  an 
evidence  that  the  drug  is  producing  the  desired  effect,  and 
the  patient  learns  after  a  short  time  to  so  grade  the  dose  as  to 
obtain  the  desired  action.  No  results  can  be  hoped  for  unless 
the  plan  is  persisted  in  for  a  considerable  period— certainly 
for  two  months— at  the  end  of  which  time,  if  the  slightest 
improvement  is  manifested,  it  should  be  continued  for  twice 
or  thrice  this  period. 

According  to  Kosegarten,*  the  remedy  exerts  a  beneficial 
action  upon  the  mucous  membrane  of  the  tympanum  also, 
causing  an  absorption  of  newly  deposited  connective  tissue. 
It  is  possible  to  observe  a  congestion  of  the  tympanic  lining 
if  the  patient  is  examined  one  or  two  hours  after  the  adminis- 
tration of  the  drug.  Politzer  advocates  the  local  application 
of  the  muriate  of  pilocarpine  to  the  mucous  membrane,  a  few 
drops  of  a  two-per-cent  solution  being  injected  through  the 
Eustachian  catheter.  Personally  I  have  no  experience  with 
this  plan. 

In  cases  of  hyperplastic  inflammation  occurring  in  ad- 
vanced life  the  auditory  nerve  may  be  found  in  a  condition  of 
torpor.  Here  strychnine  may  be  given  with  advantage,  the 
amount  being  gradually  increased  to  the  full  physiological 
limit.  This  drug  is  also  valuable  in  cases  with  pronounced 
neurasthenic  symptoms.  For  the  relief  of  distressing  tinnitus 
which  persists  in  spite  of  all  local  treatment  directed  toward 
the  middle  ear  dilute  hydrobromic  acid  will  sometimes  be 
found  efficacious.  This  is  to  be  given  well  diluted,  in  doses 
of  thirty  minims,  three  or  four  times  daily.  The  question  of 
subjective  noises  will  be  more  fully  dealt  with  under  diseases 
of  the  perceptive  apparatus.  The  possibility  of  an  hereditary 
or  an  acquired  specific  taint  should  always  be  remembered  in 
these  cases,  and  if  there  is  the  slightest  evidence  of  such  a 
factor  in   causation   the  internal  administration  of  iodide  of 

*  Archives  of  Otology,  vol.  xvii,  p.  95. 


TREATMENT— HYGIENE. 


3^^; 


potassium  is  advisable.     It  may  be  jj^iveii  either  alone  or  in 
connection  with  the  pilocarpine. 

The  question  of  the  propriety  of  treating;  the  middle-ear 
condition  when  serious  labyrinthine  involvement  coexists  is 
still  unsettled.  The  results  obtained,  no  doubt,  dither  in  in- 
dividual cases,  but  I  am  sure  that  the  rule  is  not  constant 
that  measures  directed  to  the  middle  ear  invariably  ag^jra- 
vate  the  labyrinthine  lesion.  Our  only  guide  in  the  matter  is 
to  examine  our  cases  frequently  and  observe  the  effect  of 
treatment.  If  we  find  that  inflation,  passive  motion,  or  other 
measures  directed  to  the  tympanic  condition,  produce  g^iddi- 
ness  or  an  increase  in  the  tinnitus  they  should  certainly  not 
be  persisted  in.  Numerous  instances  will  be  met  with  in 
which  exactly  the  reverse  takes  place,  the  labyrinthine  com- 
plications improviiii^  as  the  tympanic  structures  resume  a 
more  normal  condition.  From  what  has  already  been  said 
under  prognosis,  the  general  condition  of  the  patient  must  be 
kept  constantly  in  mind,  and  care  must  be  taken  to  tax  either 
his  mental  or  j>hysical  powers  a.s  little  as  j)ossiblc.  Attention 
to  the  cutaneous,  digestive,  respiratory,  and  circulatory  organs 
is  imperative  if  we  exj)ect  any  favorable  results  from  local 
measures.  It  is  not  wise  to  send  these  cases  from  home  in 
the  hope  of  obtaining  permanent  benefit  from  a  change  of 
climate,  as  the  results  obtained  by  climatic  treatment  are  at 
the  best  imcertain. 


CHAPTER    XXII. 

CHRONIC    PURULENT   OTITIS   MEDIA. 

iEtiology. — This  disease  may  follow  either  an  acute  ca- 
tarrhal or  an  acute  purulent  inflammation  of  the  tympanic 
cavity.  In  the  former  instance  it  occurs  as  the  result  of  an 
infection  of  the  discharge  through  atmospheric  impurities, 
while  as  a  sequel  of  the  latter  condition  it  represents  the  fail- 
ure upon  the  part  of  Nature  to  restore  the  affected  structures 
to  a  normal  condition.  The  term  is  often  applied  to  all 
cases  of  aural  disease  in  which  the  discharge  from  the  mid- 
dle ear  has  existed  for  more  than  two  or  three  months,  or 
even  to  cases  in  which  the  ear  is  discharging  when  the  pa- 
tient presents  for  treatment.  Exactly  when  an  affection 
ceases  to  be  acute  and  becomes  chronic  is  hard  to  deter- 
mine. For  convenience,  however,  we  may  assume  that  a 
discharge  from  the  middle  ear  which  has  failed  to  yield  to 
proper  therapeutic  measures  at  the  end  of  three  months  con- 
stitutes a  symptom  of  a  chronic  inflammatory  process. 

A  tubercular  and  occasionally  a  specific  diathesis  also  may 
give  rise  to  the  affection,  the  special  germs  of  these  diseases 
finding  lodgment  in  the  tympanum  and  setting  up  the  pecul- 
iar inflammatory  process  characteristic  of  each.  When  the 
disease  is  of  tubercular  nature  its  onset  is  so  insidious  that 
the  patient  may  not  be  able  to  state  the  exact  period  of  its 
inception,  the  first  knowledge  which  he  has  of  an  aural  affec- 
tion being  the  appearance  of  a  discharge  in  the  meatus,  while 
examination  reveals  a  condition  which  could  only  result  from 
a  chronic  inflammatory  process. 

Pathology. — When  we  find  a  purulent  discharge  from  the 
tympanum  which  has  persisted  for  a  long  period  we  are 
forced  to  conclude  that  a  certain  amount  of  tissue  necrosis 
has  taken  place.  This  is  true  whether  the  disease  was  at  first 
of  a  catarrhal  nature  or  was  purulent  from  the  beginning. 
The  infection  of  a  perfectly  innocuous  discharge  from  the 
tympanum  must  result  in  tissue  necrosis  unless  the  source  of 

(388) 


rATHOLOC.V. 


389 


infection  is  removed  at  a  very  early  period.  Those  parts  of  the 
tympanic  cavity  which  are  richly  supplied  with  connective- 
tissue  elements  form  an  excellent  nidus  for  the  development 
of  these  therms,  and  when  they  are  once  infected  it  is  prac- 
tically impossible  for  us  to  prevent  considerable  destruction 
of  tissue.  In  the  early  stages  the  connective  tissue  alone  may 
be  involved,  but  very  soon  the  osseous  structures  participate  in 
the  process,  owing  to  an  interference  with  their  proper  blood 
supply.  Those  parts  are  attacked  first  which  are  the  least 
vascular  and  whose  nutrient  vessels  arc  so  situated  as  to  be 
easily  interfered  with  by  any  increase  in  pressure  in  the  tym- 
panic cavity.  The  blood  sui)ply  of  the  incus,  it  will  be  re- 
membered, is  very  limited,  and  is  derived  from  the  j)etrosal 
branch  of  the  stylo-mastoid.  From  its  situation  its  calibre  is 
easily  obliterated  by  any  swelling  in  the  upj)cr  portion  of  the 
tympanum.  Hence  when  the  ossicular  chain  is  the  seat  of 
necrosis  the  incus  usually  sufTers  first,  caries  or  necrosis  of 
this  ossicle  being  present  in  eighty-five  per  cent  of  all  cases  in 
which  the  ossicles  are  involved.  The  process  mav  spread  to 
the  walls  of  the  tvmpanum,  usuallv  to  that  portion  of  the  ex- 
ternal wall  which  is  Inrmed  bv  the  auditorv  plate  of  the  tem- 
poral. The  internal  wall  (j1  the  middle  ear  is  seldom  aflected, 
although  it  may  be  involved  when  the  condition  is  tubercu- 
lar, or  in  cases  following  one  of  acute  infectious  diseases,  such 
as  scarlet  fever  or  diphtheria.  Since  anv  profuse  discharge 
from  the  meatus  which  has  existed  for  several  months  must 
come  from  the  middle  ear,  it  goes  without  saving  that  the 
membrana  tympani  is  perforated  in  all  cases.  The  amount  of 
local  destruction  and  the  particular  region  where  the  loss  of 
substance  occurs  varies  greatly.  Complete  destruction  of  the 
drum  membrane  is  rarely  seen,  although  the  entire  membrana 
vibrans  may  be  wanting  with  the  exception  of  the  so-called 
cartilaginous  ring,  which  marks  the  line  of  insertion  into  the 
annulus  tympanicus.  When  only  a  small  portion  of  the  drum 
membrane  is  destroved  the  perforation  most  frec]uentlv  oc- 
curs in  the  posterior  quadrant  at  the  level  of  the  umbo  or 
slightly  below  it.  When  the  osseous  structures  are  involved 
and  the  disease  has  been  of  long  duration  we  not  infrequentlv 
find  the  perforation  located  in  the  upper  and  posterior  quad- 
rant just  below  the  incudo-stapedial  articulation.  The  mem- 
brana tympani  in  these  cases  is  often  adherent  to  the  internal 
wall  of  the  middle  ear  ;  its  upper  margin,  however,  is  free, 


390  CHRONIC    PURULENT    OTITIS    MEDIA. 

and  a  probe  passed  beneath  this  may  be  directed  upward  into 
the  tympanic  vault,  following  the  long  process  of  the  incus. 
The  reason  why  this  perforation  is  so  characteristic  of  caries 
within  the  tympanum  depends  upon  the  fact  that  the  avenue 
of  exit  for  any  fluid  which  has  collected  lies  along  the  long 
process  of  the  incus.  In  fact,  this  may  be  the  only  course 
which  the  secretion  can  follow,  as  no  other  portion  of  the 
ossicular  chain  passes  from  the  upper  part  of  this  cavity  into 
the  atrium.  Anteriorly  the  atrium  is  shut  off  from  the  tym- 
panic vault  by  the  anterior  and  external  ligaments  and  by  the 
body  and  neck  of  the  malleus.  In  addition  to  these  structures, 
normally  present,  certain  reduplications  of  mucous  membrane 
are  often  found,  and  these  may  be  so  numerous  and  so  dis- 
posed as  to  render  it  impossible  for  even  air  to  pass  from  the 
vault  of  the  tvmpanum  into  the  cavity  beneath.  Perforation 
in  this  location  is  so  commonly  associated  with  caries  of  the 
incus  that  I  have  come  to  regard  it  as  almost  pathognomonic 
of  the  condition.  More  rarely  we  find  the  perforation  located 
in  the  membrana  flaccida,  either  just  above  the  short  process 
or  above  the  posterior,  or,  more  rarely,  above  the  anterior 
ligament.  A  perforation  above  the  short  process  always 
means  intratympanic  caries,  and  usually  indicates  that  the 
malleus  is  affected,  although  this  rule  is  not  invariable.  The 
extent  to  which  the  walls  of  the  tympanum  participate  in  the 
destructive  process  varies  according  to  the  care  which  has 
been  exercised  in  keeping  the  ear  properlv  cleansed,  and  the 
degree  of  infection  which  primarily  produced  the  disease. 
Constitutional  diatheses  exert  a  marked  influence  upon  the 
extent  of  involvment  of  the  osseous  walls ;  this  is  particularly 
true  of  the  tubercular  and  specific  diatheses,  the  bony  parts 
breaking  down  rapidlv  when  once  local  infection  has  taken 
place. 

Secondary  involvement  of  the  labvrinth  is  seldom  met 
with  in  chronic  suppuration.  When  present,  the  mischief  has 
usually  been  done  in  the  acute  stage  of  the  disease,  and  al- 
though both  the  oval  and  the  round  window  mav  have  re- 
mained bathed  in  pus  for  vears,  extension  to  the  labyrinth 
seldom  follows.  This  should  not  be  taken  to  mean  that  the 
lower  turn  of  the  cochlea  is  functionally  perfect  in  these 
chronic  cases.  It  is  more  reasonable  to  explain  the  slight 
changes  found  here  upon  the  ground  that  they  are  produced 
by  the  alteration  in  pressure  at  the  oval  window  due  to  adhe- 


PATHOLOGY-CHOLESTEATOMA.  391 

sions  about  the  stapes  than  to  attribute  the  condition  to  an 
infection  of  the  labyrinth. 

Secondary  involvement  of  the  mastoid  process  constitutes 
the  most  grave  complication  from  which  these  patients  suffer. 
When  drainage  through  the  external  canal  is  free  the  mastoid 
is  seldom  involved.  If,  however,  the  outflow  through  the 
canal  is  obstructed,  the  pus  finds  its  wav  into  the  pneumatic 
spaces  of  the  mastoid,  an  osteitis  is  set  up,  and  more  or  less 
extensive  bonv  destruction  takes  place.  A  change  of  con- 
siderable importance,  and  one  which  is  always  present  to  a 
greater  or  less  degree,  is  a  chronic  inflammation  involving 
the  mastoid.  This  is  esscntiallv  a  chronic  i)rolifcrative  oste- 
itis, through  which  the  pneumatic  s[)aces  are  obliterated,  and 
the  entire  mastoid  process  becomes  converted  into  dense 
eburnated  bone.  This  change  may  be  so  complete  that  all 
the  air  spaces  are  obliterated,  and  the  antrum  itself  may  be 
reduced  in  size.  Only  in  those  cases  which  have  persisted 
for  a  long  period  of  vears  and  in  which  the  process  has  been 
active  is  no  trace  of  the  atrium  found. 

The  development  of  a  cholesteatoma  following  chronic 
suppurative  otitis  depends  upon  the  inllammatory  process  as- 
suming a  particular  tvpe,  as  the  result  of  which  the  superficial 
epithelium  covering  the  mucous  membrane  is  formed  rapidlv 
and  as  rapidly  desquamated,  while  the  fluid  products  of  in- 
flammation are  slight  or  practically  absent.  As  the  result  of 
the  casting  off  of  these  eijithelial  cells  there  are  formed,  first 
in  the  vault  of  the  tympanum,  and  later  in  the  mastoid  itself, 
irregular  masses  of  epithelium,  in  which  the  cells  are  firmlv 
{)ackcd  together.  This  process  dejiends  upon  the  transforma- 
tion of  the  superficial  epithelium  lining  the  tympanum  into 
epidermal  cells.  The  change  is  probably  due  to  the  exten- 
sion of  the  cutaneous  lining  of  the  canal  into  the  middle  ear 
through  an  opening  in  the  membrana  tvnipani.  Such  a  c(jn- 
dition  follows  perforation  in  ShrapncH's  membrane  more 
commonly  than  a  solution  of  continuity  in  the  membrana 
vibrans.  In  some  instances  these  cutaneous  cells  become  com- 
pletelv  covered  by  the  mucous  membrane  and  bv  their  pro- 
liferation from  true  cysts  containing  a  mass  of  desquamated 
epithelium. 

The  cases  of  cholesteatoma  met  with  in  which  there  is 
no  evidence  of  a  previous  perforation  of  the  drum  mem- 
brane are  probably   the   result  of  an   inflammatory   process 


392 


CHRONIC    PL^RULENT    OTITIS    MEDIA. 


in  infancy,  at  which  time  the  drum  membrane  was  perfor- 
ated. 

The  acute  symptoms  which  may  be  caused  by  the  pres- 
ence of  a  cholesteatoma  and  the  treatment  of  the  condition 
will  be  considered  later.  As  these  masses  increase  in  size 
slowly  but  constantly,  they  dilate  the  cavity  in  which  they 
lie,  displacing  the  surrounding  walls.  The  mechanical  irri- 
tation, due  to  the  presence  of  the  mass,  causes  a  condensa- 
tion of  the  osseous  tissue,  or  mastoid  sclerosis.  Another 
condition  which  may  result  from  the  development  of  these 
epithelial  masses  is  absorption  of  the  bony  wall  separating 
the  meatus  from  the  mastoid  cells,  the  mastoid  cells  and  ex- 
ternal canal  being  converted  into  one  large  cavity.  If  the 
bony  walls  are  absorbed  in  the  opposite  direction,  perforation 
into  the  cranial  cavity  may  take  place.  Products  of  inflam- 
mation may  enter  the  cranial  cavity  by  transmission  through 
the  perforating  veins  or  by  local  necrosis  over  any  given  area. 
According  to  the  location  and  the  exact  nature  of  the  local 
lesion,  such  an  invasion  of  the  cranial  cavity  may  result  in  an 
epidural  abscess,  a  diffuse  meningitis,  a  brain  abscess,  or  a 
sinus  thrombosis. 

Symptomatology. — The  one  prominent  symptom  is,  natu- 
rally, discharge  from  the  ear,  and  although  extensive  destruc- 
tion may  have  taken  place,  this  may  be  the  only  symptom 
of  which  the  patient  complains.  The  amount  of  discharge 
varies,  in  some  cases  being  so  profuse  as  to  fill  the  meatus  in 
spite  of  frequent  cleansing  ;  at  other  times  being  discoverable 
only  upon  inspection  of  the  ear  by  reflected  light,  the  secre- 
tion drying  upon  the  walls  of  the  meatus  and  never  appear- 
ing at  the  orifice  of  the  canal.  The  degree  of  impairment  of 
hearing  is  never  indicative  of  the  extent  of  the  local  process. 
It  is  not  uncommon  to  find  the  entire  membrana  vibrans 
wanting,  the  incus  completely  destroyed,  and  the  malleus 
carious,  and  yet  the  power  of  audition  not  noticeably  im- 
paired. In  other  cases,  where  the  lesions  are  less  extensive, 
a  high  degree  of  deafness  is  present.  Subjective  noises  are 
much  less  frequently  met  with  in  chronic  suppuration  than  in 
the  nonsuppurative  form  of  inflammation.  Attacks  of  vertiga 
may  be  complained  of,  dependent  upon  no  assignable  cause, 
or  they  may  occur  only  when  the  ear  is  syringed.  The  dis- 
turbance of  equilibrium  may  be  but  slight  or  so  pronounced 
as  to  cause  the  patient  to  fall.     When  this  S3'mptom  appears 


SYMPTOMATOLOGY. 


393 


only  upc^n  syringing  the  ear,  tlie  drum  membrane  will  usually 
exhibit  a  large  perforation  exposing  the  head  of  the  stapes  to 
the  direct  impact  of  the  current. 

Chronic  sup)purati()n  need  not  necessarily  cause  constant 
discharge  from  the  car.  The  patient  may  be  free  from  the 
symptom  for  weeks  or  even  years.  This  intermittencv  de- 
pends upon  the  precise  nature  of  the  local  changes  within  the 
middle  ear  and  also  upon  certain  associated  conditions  of  the 
upper  air  tract.  In  children  where  the  membrana  tympani 
has  been  extensively  destroyed  as  the  result  of  one  of  the 
exanthemata,  we  frequently  have  the  history  of  a  discharge 
from  the  ear  only  when  the  patient  has  a  cold  in  the  head. 
In  such  a  case,  usually,  the  internal  wall  of  the  middle  car  is 
exposed  over  a  very  large  area,  and  the  mucous  membrane 
covering  it  participates  in  any  vascular  changes  which  may 
take  place  in  the  associated  organs.  Hence  an  acute  rhinitis 
or  an  acute  naso-pharyngitis,  especially  if  the  i)haryngeal  ton- 
sil is  hypertrophied,  causes  a  similar  hypera?mic  condition  of 
the  mucous  membrane  of  the  middle  ear.  Add  to  this  the 
exposure  of  the  membrane  bv  the  loss  of  the  membrana  tym- 
pani. and  it  is  easy  to  understand  whv  the  discharge  recurs  at 
such  a  time.  The  attack  is  reallv  one  of  tubo  tympanitis,  but 
as  the  tympanum  is  freelv  open,  the  serous  transudation  ap- 
pears in  the  canal.  In  other  instances  inquiry  will  fail  to 
elicit  anv  historv  of  discharge,  but  the  j)aticnt  may  state 
that  at  intervals  small  yellowish-brown  crusts  collect  in  the 
meatus  and  constitute  a  source  of  annoyance.  Careful  ex- 
amination shows  that  these  so-called  crusts  are  masses  of  in- 
spissated pus  which  collect  in  the  deeper  portions  of  the  canal 
and  constitute  a  source  of  discomfort  only  when  they  appear 
at  the  orifice  of  the  meatus. 

Certain  symptoms  referable  to  the  external  canal  may  also 
be  present.  The  development  of  a  fungus  upon  the  walls  of 
the  meatus  is  not  uncommon,  as  the  parts  are  continually 
bathed  in  secretion.  The  symptoms  may  be  so  slight  as  to 
escape  notice,  or  there  mav  be  an  intense  burning  or  stinging 
sensation  in  the  ear,  together  with  pruritus.  Where  proper 
attention  is  not  paid  to  cleanliness,  a  circumscribed  external 
otitis  mav  result,  producing  the  symptoms  characteristic  of 
this  affection.  Diffuse  inflammation  of  the  external  meatus  is 
rather  uncommon  unless  the  mastoid  process  is  involved. 

The  development  of  facial  paralysis  was  formerly  supposed 


394  CHRONIC    PURULENT    OTITIS    MEDIA. 

to  be  indicative  of  involvement  of  the  mastoid.  This  is  by 
no  means  true.  The  facial  nerve  in  its  passage  through  the 
tympanic  cavity  is  ordinarily  completely  inclosed  in  a  bony 
canal,  and  pressure  symptoms  are  impossible  unless  this  bony 
wall  is  wanting  at  some  portion,  either  as  an  anomalous  ana- 
tomical condition  or  as  a  result  of  necrosis.  In  either  of  these 
conditions  the  trunk  of  the  nerve  may  be  pressed  upon  and 
facial  paralysis  of  the  corresponding  side  result.  Where  the 
canal  is  imperfect  the  nerve  itself  may  become  inflamed  and 
the  integrity  of  the  facial  muscles  be  impaired  without  any 
inflammatory  changes  taking  place  in  the  bony  wall.  When 
cholesteatoma  develops,  the  pressure  upon  the  nerve  trunk 
mav  produce  this  symptom  when  the  bony  wall  has  been 
incomplete  originally  or  has  been  partially  absorbed  by 
pressure. 

The  occurrence  of  granulation  tissue  suggests  the  pres- 
ence of  necrotic  bone,  provided  the  ear  has  been  kept  thor- 
oughly cleansed,  and  its  recurrence  after  removal,  with  sub- 
sequent thorough  cleansing,  is  pathognomonic  of  diseased 
bone.  Where  the  parts  have  not  been  thoroughly  freed  from 
the  discharge  the  action  of  the  heat  of  the  body,  together 
with  the  moisture,  induces  exuberant  granulations  to  spring 
up  about  the  edges  of  the  perforation  in  the  drum  membrane, 
and  may  often  excite  a  similar  process  from  the  internal  tym- 
panic wall  or  from  the  various  reduplications  of  mucous  mem- 
brane within  the  middle  ear,  although  the  osseous  structures 
may  not  be  affected.  These  granulations,  when  they  are  due 
to  hypernutrition  of  the  soft  tissues,  yield  very  rapidly  to 
chemical  caustics  if  the  parts  are  kept  thoroughly  cleansed, 
and  a  careful  observation  of  their  behavior  under  treatment 
enables  us  to  recognize  the  involvement  of  the  bony  parts 
with  absolute  certainty.  Where  the  secretion  is  very  scanty, 
amounting  to  but  a  fraction  of  a  minim  daily,  it  may  not 
escape  from  the  meatus  at  all,  but  adhere  to  the  walls  of  the 
canal  and  form  a  crust  upon  the  posterior  or  superior  wall  of 
the  meatus.  Close  to  the  membrana  tympani  it  spreads  down- 
ward and  conceals  it  more  or  less  completely.  The  presence 
of  such  a  scale  should  always  lead  us  to  suspect  a  suppurative 
process  within  the  tympanum,  although  the  patient  may  deny 
positively  that  the  ear  has  ever  been  the  seat  of  a  purulent  dis- 
charge. In  these  cases  there  has  usuallv  been  caries  of  the 
ossicular  chain.     Most  frequently  the  incus  has  been  the  seat 


DIAC.NOSIS— PHVSICAI.    EXAMINATION. 


395 


of  the  destructive  process  which  may  have  occurred  in  early 
childhood,  although  it  may  not  be  discovered  until  adult  life. 
The  perforation  is  frequently  small  and  situated  high  up  in 
the  membrana  tympani  in  its  flaccid  portion.  It  is  in  these 
cases  that  we  may  have  serious  mastoid  complications  if  the 
condition  is  allowed  to  go  on  unchecked  ;  in  fact,  the  mas- 
toid inflammation  may  be  the  first  svmptom  which  causes 
the  patient  to  direct  his  attention  to  the  ear.  More  rarely 
the  case  is  still  more  serious  and  intracranial  infection  takes 
place  and  progresses  so  insidiouslv  that  the  j^aticnt  is  bcvond 
all  hope  before  the  trouble  is  disc(n'ered. 

The  symptoms  which  characterize  labyrinthine  involve- 
ment are  sudden  dizziness,  nausea,  and  profound  deafness.  A 
moderate  involvement  of  the  labvrinthine  structures  is  com- 
mon in  cases  where  the  disease  has  persisted  for  a  long  pe- 
riod. Notwithstanding  this  fact,  the  hearing  mav  be  but  lit- 
tle impaired,  the  labvrinthine  atTecfion  being  contined  to  that 
p)art  of  the  organ  which  is  concerned  in  the  appreciation  in 
the  highest  notes  of  the  scale — tones  which  are  but  little  usetJ 
in  carrving  on  the  ordinarv  vocations  of  life. 

Diagnosis. ^ — A.  Physical  Exawinatiou. —  It  is  impossible  to 
describe  the  manifold  appearances  which  mav  be  observed 
in  chronic  purulent  otitis.  For  convenience  we  may  divide 
them  presented  into  six  groups: 

I.  Destruction  of  the  membrana  tympani  over  a  large  area, 
with  thickenine:  of  the  mucous  membrane  over  the  internal 


^       V 


Fig.      io6. — Chronic  Fic.  107. — Chronic  puru-  Kk;.  108. — Chronic  puru- 

purulent  otitis  me-  lent  otitis  media.     Ex-  lent  otitis  media.   Mem- 

dia.    Extensive  de-  uberant  granulation  tis-  hrana  tympani  adherent 

struction     of     the  sue  developing  within  along  inferior  margin  of 

membrana  vibrans.  the  tympanum.  perforation. 

tympanic  wall  and  hypersecretion  from  the  exposed  surface 
(Fig.  106). 

2.  Extensive  destruction  of  the  membrana  vibrans.  with  the 
development  of  granulation  tissue  over  the  internal  wall  of  the 
middle  ear  (Fig.  107). 

3.  But  slight  destruction  of  the  membrana  vibrans,  usually 


396 


CHRONIC    PURULENT    OTITIS    MEDIA. 


in  the  posterior  quadrant ;  adhesions  between  the  margin  of 
the  perforation  and  the  internal  tympanic  wall,  except  at  the 
upper  border,  where  a  sinus  leads  directly  into  the  vault  of 
the  tympanum.  In  these  cases  granulation  tissue  ma)-  be 
present,  protruding  from  the  orifice  of  the  sinus,  or  the 
channel  may  be  perfectly  free.  This  appearance  is  indicative 
of  caries  within  the  middle  ear  (Fig.  io8). 

4.  Membrana  vibrans  intact ;  perforation  through  the  mem- 
brana  flaccida,  above  the  short  process  of  the  malleus.  'Here 
granulation  tissue  may  or  may  not  be  present.  The  appear- 
ance is  always  indicative  of  diseased  bone  (Fig.  109). 

5.  Entire  membrane  swept  away,  except  the  cartilaginous 
ring  and  a  small  portion  of  Shrapnell's  membrane  which  en- 


FlG.  109. —  Perfora- 
tion above  the 
short  process  of 
the  malleus. 


Fig.  1 10. — Chronic 
purulent  otitis  me- 
dia. Ossicles  dis- 
placed. 


Fig.  III. — Chronic  puru- 
lent otitis  media.  Small 
perforation  behind  the 
umbo. 


velops  the  ossicula  or  their  remnants,  partial  destruction  of 
the  chain,  as  a  rule,  having  taken  place.  In  these  cases  there 
is  usually  a  sinus  beneath  the  anterior  or  posterior  ligament, 
sometimes  in  both  situations  (Fig.  no). 

6.  A  small  perforation  through  the  membrana  vibrans,  the 
drum  membrane  otherwise  intact.  This  appearance  is  met 
with  in  childhood,  and  is  indicative  of  infection  of  a  simple 
catarrhal  inflammation  of  the  tympanic  cavity,  due  usually  to 
neglect  (Fig.  1 1 1). 

In  inspecting  any  case,  particular  attention  should  be  paid 
to  an  investigation  of  the  entire  periphery  of  the  membrana 
tympani.  Not  only  the  membrana  vibrans,  but  especially  that 
part  lying  about  the  short  process,  should  be  carefully  exam- 
ined. This  latter  step  should  be  taken,  although  a  perforation 
may  be  present  in  the  lower  portion  of  the  drum  membrane, 
which  seems  to  explain  sufficiently  the  presence  of  the  dis- 
charge. A  coexistent  loss  of  substance  in  Shrapnell's  mem- 
brane may  be  found  which  will  modify  decidedly  the  prog- 
nosis in  the  case. 


DIAGNOSIS— PHYSICAL    EXAMINATION. 


397 


The  free  use  of  the  probe  is  not  difficult  in  these  cases, 
since  the  middle  ear  is  scarcely  sensitive.  We  should  deter- 
mine whether  the  discharge  really  proceeds  from  an  exposed 
surface  or  simply  flows  over  this,  originating  in  the  upper  part 
of  the  tvmpanic  cavitv.  When  this  is  the  case,  it  will  alwavs 
be  possible  to  insert  a  delicate  probe  under  the  posterior  or 
anterior  f(jld  and  carrv  it  upward  into  the  vault.  The  sim- 
plest means  of  doing  this  is  to  wind  a  pledget  of  cotton  firmlv 
upon  a  small  cotton-holder,  the  cotton  extending  for  some  dis- 
tance bevond  the  end  of  the  instrument.  If  wound  tirmlv, 
this  cotton  tip  possesses  considerable  power  of  resistance, 
and  causes  less  pain  upon  imj)act  than  does  a  metallic  in- 
strument. The  cotton  should  be  bent  at  a  right  angle,  the 
angular  portion  being  about  one  eighth  of  an  inch  in  length. 
It  is  sufficientlv  firm  to  ))ermit  its  introduction  beneath  the 
anterior  or  posterior  fold  of  the  membrana  or  into  the  small 
perforation  in  its  lower  portion.  Bv  manipulation  it  should 
be  carried  successivelv  to  the  different  parts  of  the  middle 
ear,  when,  if  exposed  bone  is  encountered,  the  operator  will 
recognize  the  fact  bv  the  cotton  catching  upon  the  rough 
surface.  When  this  is  not  felt,  it  is  well,  upon  removing  the 
instrument,  to  examine  the  cotton  carefullv  bv  means  of  a 
magnifving  glass.  Contact  with  exposed  bone  will  j)ull  out 
some  of  the  strands,  and  this  sign  is  as  positive  an  evidence 
of  caries  as  that  afforded  bv  the  use  of  the  probe  in  any  other 
portion  of  the  bodv. 

Granulation  tissue  mav  develop  to  such  an  extent  as  to 
completely  fill  the  meatus,  in  which  case  its  recognition  is  a 
matter  of  no  difficult  v.  In  cases  where  it  comes  through  a 
perforation  in  the  membrana  flaccida,  it  may  be  so  closely 
applied  to  the  peripherv  of  the  perforation  as  to  render  the 
line  of  demarcation  almost  indistinguishable.  Here  the  mis- 
take mav  be  made  of  confounding  the  appearance  with  a 
bulging  of  the  upper  portion  of  the  drum  membrane,  but 
careful  manipulation  with  the  probe  will  reveal  the  true  na- 
ture of  the  condition.  The  granulation  tissue  pits  easily  on 
pressure,  and  the  slight  amount  of  mobilitv  which  it  possesses 
points  clearly  to  a  pedunculated  attachment. 

The  mucous  membrane  covering  the  internal  tympanic 
wall  mav  resemble  so  closely  the  appearance  of  a  bulged  and 
reddened  drum  membrane  as  to  mislead  us,  unless  we  bear  in 
mind  that  where  the  membrana  tympani   is  present  we  are 


398  CHRONIC    PURULENT    OTITIS    MEDIA. 

able  to  follow  any  one  wall  of  the  canal  continuously  across 
the  fundus  until  it  merges  into  the  opposite  wall,  the  outline 
being  unbroken.  If  we  are  dealing  with  a  case  in  which  the 
internal  wall  of  the  middle  ear  is  exposed,  we  shall  find  a 
solution  of  continuity  at  the  very  periphery,  between  the 
margin  of  the  canal,  which  stops  here  abruptly,  and  the  red- 
dened wall  of  the  middle  ear,  which  lies  at  a  lower  level. 
The  recollection  of  this  simple  fact  will  render  a  mistake  in 
diagnosis  rare. 

The  recognition  of  the  ossicula  is  frequently  a  matter  of 
no  small  difificulty.  The  short  process  of  the  malleus  usually 
preserves  its  normal  position  more  nearly  than  any  of  the 
other  landmarks,  and  should  be  first  sought.  When  this  is 
recognized,  if  the  shaft  is  present,  we  can  usually  make  it  out. 
If  it  does  not  lie  in  its  normal  position,  or  if  it  is  found  to  be 
slightly  displaced  backward  and  inward,  the  head  of  the 
patient  should  be  tilted  far  over  toward  the  opposite  side  and 
the  region  between  the  short  process  and  the  internal  tym- 
panic wall  carefully  inspected.  Necrosis  of  the  tip  of  the 
malleus  is  not  uncommon,  and  then  the  manubrium  is  usually 
slender,  and  drawn  upward  and  inward  by  fibrous  bands  and 
completely  hidden  from  view  by  the  prominent  short  process 
and  the  hypertrophied  posterior  and  anterior  folds. 

It  is  of  special  importance  to  inspect  the  upper  and  pos- 
terior quadrant  of  the  field  for  an  explanation  of  the  degree 
of  functional  impairment.  The  stapes  may  frequently  be  seen 
in  this  region  lying  close  to  the  margin  of  the  tympanic  ring, 
and  partially  concealed  by  it.  If  the  head  of  the  patient  is 
inclined  well  to  the  opposite  side,  and  at  the  same  time  tilted 
a  little  backward,  we  are  able  to  look  beneath  the  obstruct- 
ing margin,  and  can  usually  recognize  the  head  of  the  ossicle. 
Where  extensive  destruction  has  taken  place  the  long  process 
of  the  incus  is  often  wanting  ;  if  present,  it  may  occupy  its 
normal  position,  the  incudo-stapedial  articulation  being  clearly 
visible.  When  the  lower  portion  alone  is  destroyed  the  rem- 
nant is  usually  displaced  toward  the  malleus,  lying  between 
the  manubrium  mallei  and  the  head  of  the  stapes. 

Too  much  stress  can  not  be  laid  upon  the  importance  of 
first  cleansing  the  ear  most  thoroughly  by  means  of  the  cot- 
ton pledget  and  employing  the  probe,  lightly  touching  each 
prominent  point  before  attempting  to  interpret  the  condition 
of  the  parts.     In  an  ear  which  has  been  properly  cleansed  an 


DIAGNOSIS— FUNCTIONAL    EXAMINATION. 


399 


exact  diagnosis  is  not  difficult  it  the  normal  anatomical  posi- 
tion of  the  parts  is  borne  in  mind.  Where  any  secretion  is 
present  an  exact  diagnosis  is  impossible,  and  a  correct  inter- 
pretation is  the  result  more  of  good  luck  than  of  skill.  In 
addition  to  the  ossicula,  certain  landmarks  may  be  recognized 
on  the  internal  tympanic  wall.  In  the  anterior  quadrant, 
either  partly  below  or  above  the  median  plane,  there  is  a 
hemispherical  depression  just  at  the  margin  of  the  ring,  which 
marks  the  tympanic  orifice  of  the  Eustachian  tube.  In  the 
posterior  quadrant  the  promontory  terminates  close  to  the 
tympanic  ring.  This  break  in  the  outline  marks  the  niche  of 
the  round  window  lying  below  the  head  of  the  stapes,  and  in 
a  plane  almost  at  right  angles  to  the  plane  of  the  oval  win- 
dow. Occasionally  the  niche  of  the  fenestra  rotunda  is  ex- 
ceedingly well  marked,  and  when  associated  with  a  contrac- 
tion of  the  meatus  at  its  inner  end  the  promontory  may  be 
mistaken  for  an  exostosis. 

Inflation  by  means  of  the  catheter  gives  auscultatory 
sounds,  which  vary  according  as  the  middle  car  is  shut  off 
from  the  Eustachian  tube  by  adhesions,  or  where  the  tym- 
panic orifice  is  patent.  When  the  inner  extremity  of  the 
tube  has  been  occluded  by  an  hypertrophic  process,  no  sound 
of  air  entering  the  tympanum  is  perceived,  each  compression 
of  the  bulb  being  heard  as  a  faint,  distinct,  percussion  sound. 
It  is  distinguished  from  the  sound  heard  when  the  tube  is 
occluded  at  the  isthmus  from  the  more  immediate  proximity 
to  the  ear  of  the  observer,  and  also  by  the  absence  of  mucous 
pharyngeal  rhonchi.  which  usually  accompany  this  latter  con- 
dition. With  a  latent  tube  the  sound  varies  from  a  full  blow- 
ing sound  where  the  perforation  is  large  to  a  sharp  whistling 
note  when  the  air  passes  through  a  small  opening.  Fre- 
quently perforations  in  the  upper  part  of  the  drum  membrane 
do  not  modify  the  normal  auscultatory  signs  because  the 
tympanic  vault  is  entirely  shut  off  from  the  atrium  by  viscid 
pus  or  by  adhesions,  and  inflation  produces  the  characteristic 
impact  sound  as  the  air  impinges  upon  the  drum  membrane. 

B.  Functional  Examination. — The  hearing  for  sharp  sounds 
is  reduced,  and  conversational  voice  and  whispered  speech 
may  be  heard  as  well  or  better  than  either  the  watch  or  acou- 
meter.  The  lower  tone  limit  is  elevated  ;  the  upper  tone 
limit  is  frequently  normal,  especially  where  the  parts  are 
moist,  and  where  the  process  has  not  existed  for  many  years. 


^OO  CHRONIC    PURULENT    OTITIS    MEDIA. 

In  some  cases  we  lind  that  high  notes  are  better  perceived 
than  under  normal  conditions.  Where  the  ear  has  been  the 
seat  of  a  purulent  inflammation  for  a  long  period  of  years, 
the  upper  tone  limit  is  often  considerably  lowered.  This 
indicates  labyrinthine  involvement,  which  is  usually  not  pro- 
o-ressive.  Bone  conduction  is  increased  in  most  cases.  Where 
one  side  alone  is  affected,  the  tuning  fork  on  the  vertex  is 
heard  better  bv  the  affected  ear  ;  the  normal  ratio  between 
bone  and  air  conduction  is  reversed  for  the  lower  notes  of  the 
scale,  frequently  for  all  notes  below  the  c" — 512  V.  S.  The 
electrical  irritability  is  usually  increased  while  the  middle-ear 
process  is  active  ;  when  this  is  quiescent  such  a  reaction  to 
the  galvanic  current  would  be  indicative  of  labyrinthine  in- 
flammation or  congestion. 

Involvement  of  the  mastoid  process  is  characterized  by 
pain  and  tenderness  over  the  mastoid  region  externally,  and 
usually  by  a  diminution  in  the  amount  of  discharge.  Within 
the  canal  we  find  the  parts  tender  along  the  superior  and  pos- 
terior walls  close  to  the  tympanic  ring.  Very  soon  after  the 
mastoid  has  been  attacked  the  soft  tissues  in  this  region  sag 
into  the  lumen  of  the  meatus,  narrowing  the  fundus,  and  in 
severe  cases  may  lie  in  contact  with  the  opposite  wall.  This 
prolapse  of  the  supero-posterior  wall  of  the  bony  canal  is 
pathognomonic  of  an  inflammatory  process  within  the  mas- 
toid, and  we  need  no  other  indication  before  resorting  to  im- 
mediate operative  measures.  The  temperature  is  in  nowise 
indicative  of  extension  in  this  direction ;  quite  frequently  the 
temperature  remains  normal,  although  the  pneumatic  spaces 
in  communication  with  the  tympanic  cavity  have  become  in- 
volved. 

Prognosis. — We  consider  under  prognosis,  first,  the  degree 
of  functional  impairment  which  the  patient  will  suffer  ;  sec- 
ond, the  continuance  or  cessation  of  the  discharge;  third,  the 
danger  to  life. 

In  considering  the  probable  degree  of  functional  impair- 
ment, we  must  remember  in  general  that  a  suppurative  inflam- 
mation endangers  the  hearing  much  less  than  does  a  nonsup- 
purative process.  The  amount  of  destruction  that  has  resulted 
furnishes  us  few  data  upon  which  to  base  an  opinion.  The 
condition  of  the  parts  in  the  upper  and  posterior  quadrant, 
however,  may  aid  us  in  estimating  the  probable  degree  of  im- 
pairment which  will  result;  if  the  stapes  is  exposed  and  is 


PROGNOSIS.  401 

movable  upon  manipulation  and  the  niche  of  the  round  win- 
dow is  unobstructed,  deterioration  of  the  hearing  should  not 
take  place  beyond  that  originally  present  when  the  patient 
first  comes  under  observation  ;  on  the  contrary  we  should 
expect  it  to  improve  considerably  from  the  reduction  of  the 
inflammatory  process  and  from  surgical  measures  directed  to- 
ward adhesions  which  may  be  present.  When  the  stapes  can 
not  be  seen  but  adhesions  exist  which,  from  their  location, 
might  fix  it  firmly,  the  chances  of  improvement  are  still  good. 
With  a  normally  movable  stapes  and  where  the  round  window 
is  not  occluded,  it  is  not  probable  that  anv  measure  directed 
toward  the  middle  ear  will  greatlv  increase  the  power  of  au- 
dition. In  interpreting  these  appearances  we  naturally  cor- 
relate the  results  of  the  functional  and  physical  examinations. 
With  labyrinthine  involvement  we  may  hope  for  improvement 
from  internal  medication,  although  a  guarded  opinion  should 
be  given  as  to  the  degree  which  will  be  attained. 

Concerning  the  cessation  of  discharge,  the  chief  factor  is 
the  presence  or  absence  of  diseased  bone  and  the  extent  to 
which  the  osseous  ti.ssues  have  been  invaded.  If  we  find  that 
the  bony  ring  has  been  involved  and  the  disease  is  of  long 
duration,  it  is  quite  probable  that  softening  has  occurred  in 
regions  inaccessible  to  instruments  introduced  through  the 
meatus.  If  the  ossicula  alone  are  the  seat  of  the  necrotic  pro- 
cess or  if  we  believe  that  the  walls  of  the  middle  ear  are  but 
slightly  involved,  our  prognosis  is  then  fairly  good  regarding 
the  ultimate  cessation  of  the  otorrhoea.  When  no  dead  bone 
is  present  we  should  be  able  to  promise  absolutely  that  the 
discharge  will  cease  under  proper  treatment.  We  can  also 
promise  that  the  danger  of  subsequent  mastoid  involvement 
will  be  removed.  But  in  an)'  given  instance  where  the  osseous 
structures  have  been  invaded,  to  promise  absolutely  that  the 
discharge  will  cease,  is  certainly  unwise. 

Concerning  the  danger  to  life,  we  need  only  to  remember 
that  insurance  companies  constantly  reject  applicants  suffer- 
ing from  a  chronic  otorrhoea,  to  appreciate  how  grave  a  men- 
ace to  life  the  condition  is.  Where  the  mastoid  is  not  involved 
and  an  examination  reveals  no  evidence  of  intracranial  involve- 
ment at  the  time  of  the  investigation,  we  can  promise  that  by 
properly  conducted  treatment  the  process  will  not  endanger 
the  life  of  the  patient.  With  mastoid  involvement  there  is  al- 
ways a  certain  element  of  danger  dependent  upon  the  degree  ; 
27 


402  CHRONIC   PURULENT   OTITIS   MEDIA. 

when  intracranial  changes  have  already  taken  place  the  prog- 
nosis is  very  grave.  The  variations  in  conditions  which  influ- 
ence our  opinion  when  the  mastoid  is  involved  will  be  fully 
discussed  in  a  chapter  on  this  subject.  Subjective  noises,  as 
a  rule,  are  not  distressing  in  the  disease  under  discussion  ;  but 
when  present,  it  is  difficult  to  secure  a  complete  subsidence  of 
tinnitus  unless  it  results  from  an  acute  exacerbation  of  the 
chronic  disease. 

Treatment. — In  the  treatment  of  these  cases  we  endeavor 
to  accomplish  two  results  :  first,  to  stop  the  discharge  ;  sec- 
ond, to  improve  the  hearing  and  relieve  the  subjective  dis- 
turbances if  any  are  present. 

In  order  to  accomplish  the  first  purpose  it  is  necessary  to 
see  that  the  ear  is  kept  thoroughly  cleansed  in  order  that  the 
combined  influence  of  heat  and  moisture  may  be  removed."  If 
the  patient  is  to  be  treated  at  the  hands  of  the  surgeon  every 
day  and  the  discharge  is  only  moderate  in  quantity,  this  may 
be  removed  in  whatever  way  seems  advisable,  either  with  the 
cotton  pledget  or  by  irrigation  with  the  syringe.  If  the  treat- 
ment is  to  be  conducted  by  the  patient,  irrigation  affords  the 
only  safe  means  by  which  this  object  can  be  effected.  The 
frequency  with  which  irrigation  should  be  repeated  depends 
on  the  quantity  of  discharge,  which  must  not  be  allowed  to 
accumulate  in  the  canal.  In  children,  where  the  process  is 
very  active,  or  in  cases  that  have  been  neglected  for  a  long 
time,  it  is  well  to  begin  by  having  the  ear  syringed  every  two 
hours.  The  attendant  or  the  patient  himself  must  be  in- 
structed carefully  in  the  manner  of  performing  this  apparently 
simple  operation.  In  the  large  majority  of  instances  if  this  is 
not  done  the  pus  will  not  be  thoroughly  removed  from  the 
canal  by  the  procedure ;  consequently  particular  attention  is 
directed  to  this  point.  In  the  adult  patient  the  ear  is  to  be 
drawn  upward  and  backward  by  grasping  the  auricle  between 
the  index  and  middle  fingers  of  the  left  hand,  thus  straight- 
ening the  auditory  meatus.  The  syringe  should  have  a  blunt 
nozzle,  rendering  it  impossible  for  it  to  be  carried  in  the 
meatus  far  enough  to  impinge  upon  the  membrana  tympani. 
After  the  irregularities  in  the  canal  have  been  overcome  in 
the  manner  described,  the  syringe  should  be  introduced  into 
the  meatus  as  far  as  possible  and  directed  inward  and  slightly 
downward  and  forward  toward  the  tip  of  the  nose.  In  young 
children  the  curves  of  the  canal  are  best  obliterated  by  pull- 


TECHNIQUE   OF   SYRINGING.  403 

ins:  the  auricle  outward  and  downward,  as  shown  in  Fier.  87 
If  the  syringe  is  pointed  upward  and  inward  the  fluid  will 
cleanse  the  deeper  parts  more  thoroughly  than  if  the  direc- 
tions just  given  for  the  use  of  the  syringe  in  adult  patients 
are  followed.  The  irrigating  fluid  is  injected  with  a  moderate 
amount  of  force,  and  the  return  current  holding  the  pus  in 
suspension  is  allowed  to  flow  into  any  convenient  receptacle 
which  the  attendant,  or  even  the  patient  himself,  holds  under 
the  ear  close  to  the  side  of  the  face.  The  temperature  of  the 
fluid  is  a  matter  of  considerable  importance  ;  b(^th  hot  and 
cold  solutions  are  painful  when  introduced  into  the  meatus. 
and  the  sensations  of  the  patient  should  guide  us  in  choosing 
the  proper  temperature.  The  amount  to  be  used  at  each 
irrigation  should  not  be  less  than  half  a  pint,  and  it  is  fre- 
quently advisable  to  use  more. 

Concerning  the  choice  of  a  fluid  for  this  purpose,  we  may 
use  either  a  bichloride-of-mercury  solution  (1  to  5,000  or  i  to 
8,000)  or  water  which  has  been  boiled  and  allowed  to  cool  to 
a  lukewarm  temperature,  or  a  saturated  solution  of  boric  acid, 
(jr  a  two-per-cent  solution  of  carbolic  acid,  or  any  other  con- 
venient solution.  In  cases  which  have  formerly  been  under 
treatment,  and  the  patients  know  by  experience  the  effect 
which  fluids  have  upon  the  ear,  the  surgeon  may  be  told 
occasionally  that  the  result  of  the  so-called  "  wet  treatment  " 
has  been  to  increase  the  discharge.  Many  of  these  [)atients 
are  able  to  wipe  out  the  ears  very  successfully  with  a  small 
pledget  of  cotton  twisted  about  a  bit  of  wood  or  upon  a 
metallic  cotton  holder.  We  should  never  disregard  these 
statements  on  the  part  of  the  patient  without  some  good 
reason,  and  it  is  well  not  to  insist  upon  the  use  of  fluids  if 
there  is  evidence  that  these  have  formerly  increased  the 
trouble. 

The  removal  of  the  discharge  causes  the  swelling  of  the 
tissues  within  the  middle  ear  to  diminish,  and  with  the  disap- 
pearance of  the  congestion  and  oedema  the  discharge  will 
diminish  in  quantity  and  the  parts  resume  their  normal  ap- 
pearance. 

We  should  now  carefullv  investigate  as  to  the  cause  of  the 
flow.  If  we  find  the  mucous  membrane  within  the  middle 
ear  exposed  over  a  large  area,  as  is  the  case  when  considera- 
ble of  the  membrana  tympani  has  been  destroyed,  and  the 
exposed  mucous  membrane  is  swollen,  hypertrophied,  turges- 


404  CHRONIC   PURULENT   OTITIS   MEDIA. 

cent,  and  moist,  the  indication  is  to  cause  an  absorption  of 
the  hypertrophied  tissue  and  restore  the  local  circulation  to 
a  normal  condition.  Certain  conditions  of  the  upper  air  pass- 
ages may  tend  to  keep  up  a  state  of  chronic  congestion  within 
the  middle  ear,  and  investigation  of  the  nose  and  naso-pha- 
rynx  should  never  be  omitted. 

Where  adenoid  vegetations  are  found,  it  is  well  to  begin 
our  treatment  by  their  removal.  Enlarged  faucial  tonsils  do 
not  as  frequently  cause  trouble,  but  if  the  organs  are  excess- 
ively hypertrophied,  they  should  be  removed.  Hypertrophy 
of  the  turbinated  bodies  or  other  marked  obstructive  condi- 
tions in  the  nasal  cavity  also  demand  treatment,  in  order  that 
there  shall  be  no  barrier  to  the  free  venous  flow  from  the 
middle  ear. 

Applications  should  also  be  made  to  the  exposed  lining 
membrane  of  the  tympanum.  For  this  purpose  solutions  of 
nitrate  of  silver  may  be  employed,  beginning  with  a  two-per- 
cent solution,  and  rapidly  increasing  the  strength,  according 
to  indications,  up  to  two  hundred  and  forty  grains  to  the 
ounce,  if  necessary.  The  copper  salts,  if  employed,  should  be 
used  in  less  saturated  solutions — ordinarily  of  a  strength  of  not 
more  than  ten  grains  to  the  ounce.  The  practice  of  allowing 
these  patients  to  instil  astringent  solutions  into  the  ear  is  not 
advisable,  particularly  aqueous  solutions  of  sulphate  of  zinc 
with  a  small  amount  of  glycerin  added,  to  retain  the  astrin- 
srent  for  a  longer  time  in  contact  with  the  mucous  membrane. 
A  solution  of  this  sort  affords  an  excellent  soil  for  the  devel- 
opment of  the  various  vegetable  molds,  and  this  occurrence 
often  follows  its  continued  use.  If  the  patient  is  able  to  visit 
the  surgeon  only  occasionally  the  preparation  which  is  best 
adapted  for  his  use  at  home  is  an  alcoholic  solution  of  boric 
acid  in  the  proportion  of  twenty  grains  to  the  ounce.  Where 
the  internal  wall  of  the  tympanum  is  exposed  over  a  large 
area,  this  solution  produces  particularly  good  results,  the  alco- 
hol acting,  as  a  local  stimulant  to  the  parts,  while,  in  combi- 
nation with  boric  acid,  it  possesses  sufficient  antiseptic  prop- 
erties to  keep  the  parts  free  from  the  development  of  any  of 
the  low  vegetable  organisms.  It  also  exerts  a  decided  astrin- 
gent action,  preventing  the  formation  of  granulation  tissue. 

The  use  of  powders  which  the  patient  is  to  blow  into  the 
ear  can  not  be  too  strongly  condemned.  Under  no  condition 
should  the  patient  be  supplied  with  any  remedy  in  this  form. 


INSUFFLATION   OF   POWDERS.  ^05 

Even  in  cases  where  the  perforation  is  very  large,  it  is  pos- 
sible for  a  preparation  of  this  character  to  dry  into  a  firm 
crust  after  absorbing  the  discharge,  and  this  crust  may  be- 
come so  closely  attached  as  to  constitute  a  barrier  to  the  free 
outflow  of  secretion,  in  case  this  becomes  suddenly  augmented 
in  quantity  at  any  time.  Pus  retention  under  these  circum- 
stances does  not  dilfer  from  retention  of  purulent  material 
from  any  other  cause,  and  in  a  considerable  number  of  cases 
death  has  resulted  from  the  incautious  use  of  powders.  In 
the  hands  of  the  surgeon  some  of  the  astringent  or  stimu- 
lating powders  are  of  great  value.  We  sometimes  find 
that  after  the  discharge  has  been  greatly  reduced  a  small 
amount  of  moisture  still  persists,  and  the  progress  of  the  case 
stops  at  this  point.  The  use  of  fluids  in  these  cases  seems  to 
tend  rather  to  keep  up  the  discharge.  The  insufflation  of  a 
minute  quantity  of  boric  acid,  oxide  of  zinc,  iodoform,  or  a 
mixture  of  equal  parts  of  alum  and  boric  acid  is  frequently 
followed  by  a  complete  cessation  of  secretion,  the  ear  remain- 
ing perfectly  dry.  The  fact  must  be  cnijihasized  that  but  a 
minute  quantity  of  any  such  preparation  is  to  be  used,  just 
sufficient  to  cover  the  mucous  membrane.  In  the  case  of 
boric  acid  a  little  mav  also  be  dusted  ujion  the  walls  of  the 
meatus,  but  the  practice,  sometimes  recommended,  of  filling 
the  canal  with  the  powder  should  never  be  adopted.  In  no 
case  should  powder  be  used  even  by  the  surgeon  if  an  inter- 
val of  more  than  fortv-cight  hours  is  to  cla[)se  before  the  next 
visit,  and  the  patient  should  be  directed  immediatelv  to 
syringe  the  ear  thoroughl}-  if  at  anv  time  there  is  pain,  giddi- 
ness or  a  considerable  increase  in  the  discharge.  With  these 
precautions  I  thoroughly  approve  of  the  use  of  powders,  but 
under  no  other  circumstances. 

In  other  cases  we  find  that  our  efforts  are  unsuccessful, 
although  most  carefully  conducted.  This  should  always 
cause  the  suspicion  of  diseased  bone  in  some  portion  of  the 
tympanic  cavity.  Naturally  this  has  already  been  sought 
in  the  first  examination,  but  if  treatment  has  been  consci- 
entiously carried  out  in  the  manner  described  for  a  period 
of  three  to  four  weeks  without  reducing  the  quantity  of 
the  discharge  considerably  we  may  assume  safely  that  dis- 
eased bone  is  the  cause  of  the  trouble.  This  applies  to  cases 
where  no  granulation  tissue  is  present;  in  many  instances  we 
find  this  additional  symptom.     Where,  upon  primary  exami- 


_^o6  CHRONIC   PURULENT   OTITIS    MEDIA. 

nation,  exuberant  granulations  are  present  to  such  a  degree 
as  to  fill  the  fundus  of  the  canal,  or  even  if  confined  to  a 
limited  area,  these  should  be  dealt  with  before  methods  other 
than  simple  cleansing  are  instituted.  If  the  granulations  are 
of  small  size  they  may  be  destroyed  t/i  situ  by  the  chemical 
or  potential  cautery.  The  chemical  agents  employed  for  this 
purpose  are  chromic  acid  or  silver  nitrate,  either  of  which 
may  be  fused  upon  the  end  of  a  metal  probe  and  lightly  ap- 
plied to  the  granulation  tissue  after  thoroughly  drying  the 
area  to  be  touched.  Any  excess  of  the  agent  must  be  wiped 
away  by  means  of  a  dry  pledget  of  cotton  to  prevent  it  from 
spreading  over  the  entire  lining  membrane  of  the  middle  ear. 


Fig.  112. — Removal  of  aural  polyp  with  the  snare. 

Where  the  tissue  is  soft  and  but  little  elevated  above  the 
general  surface  of  the  mucous  membrane,  a  saturated  solu- 
tion of  persulphate  of  iron  may  be  employed.  Chromic  acid 
is  more  suitable  for  the  destruction  of  large  granulations 
than  any  other  chemical  agent,  since  severe  inflammatory  re- 
action very  rarely  follows  its  use.  The  manipulation  of  the 
actual  cautery  is  difficult,  and  is  rarely  more  efficient  than 
the  means  above  mentioned.  Where  the  granulations  are 
of  larger  size  they  should  be  removed  by  means  of  the  cold 
wire  snare  (Fig.  112),  the  loop  being  carried  upward  to  the 
base  and  made  to  surround  it,  when  by  drawing  the  wire 
into  the  tube  of  the  snare  the  sfrowth  is  cut  off  close  to  its  at- 


REMOVAL   OF    AURAL   POLYPS. 


407 


113. —  Removal   of  aural   polyp  with 
the  sharp  curette  (natural  size). 


tachment.  I  much  prefer  this  method  to  evulsing  the  growth 
after  it  has  been  surrounded  by  the  loop.  A  practice  which  I 
often  employ  in  these  cases  is  removal  of  the  tissue  by  means 
of  the  sharp  curette  (Fig.  1 1 3). 
Instruments  of  various  sizes 
are  necessary  in  order  to  per- 
form the  operation  effective- 
ly in  this  manner.  The  cu- 
rette is  carried  into  the  canal, 
passed  below  the  growth, 
and  then  raised  so  that  the 
ring  of  the  instrument  will 
encircle  it ;  by  moving  the 
curette  delicately  it  can  be 
carried  upward  along  the 
pedicle  to  its  point  of  attach- 
ment:  then,  bv  pressing  the 
instrument  firmlv  against 
the  wall  of  the  canal,  and  at 
the  same   time   drawing    it  outward,   the   mass    is   removed. 

This  procedure  is  not  j)ainful  if  care  is  taken  not  to  touch 
the  walls  of  the  meatus  during  the  introduction  of  the  instru- 
ment. The  advantage  of  this  method  lies  in  the  thorough 
extirpatitin  of  the  mass,  which  is  usually  severed  close  to  its 
base.  After  removal,  a  j)ledget  of  cotton  is  inserted  into  the 
canal  and  crowded  rather  firmly  into  the  fundus  to  check 
whatever  hxmorrhage  may  occur.  After  a  few  moments  it  is 
removed  and  the  parts  thoroughly  cleansed  by  the  cotton 
pledget,  after  which  the  stump  is  cauterized.  If,  after  a 
thorough  removal  in  this  manner  and  careful  cleansing  of  the 
ear  for  a  period  of  several  days,  the  tissue  reappears,  dead 
bone  is  certainly  present.  No  other  condition  but  the  pres- 
ence of  a  foreign  body  can  cause  this  phenomenon,  and  meas- 
ures should  at  once  be  instituted  to  remove  the  ofTending 
substance. 

It  often  happens,  in  an  ear  which  has  been  the  seat  of  puru- 
lent process  since  early  childhood,  that  the  discharge  ceases 
and  the  ear  remains  practically  dry,  but  occasionally  a  small 
amount  of  offensive  discharge  appears  at  the  meatus.  It  will 
frequently  be  found  that  this  symptom  is  due  to  the  presence 
of  an  aspergillus  which  has  found  lodgment  and  subsequently 
developed  in  the  meatus  or  upon  the  internal  tympanic  wall. 


4o8  CHRONIC    PURULENT    OTITIS    MEDIA. 

Owing  to  the  presence  of  a  slight  amount  of  moisture  it 
has  developed  in  this  situation,  and  afterward  its  presence 
increases  the  discharge,  and  thus  facilitates  its  own  growth. 
This  fact  is  mentioned  since  its  occurrence  may  mislead  us  as 
to  the  result  obtained  by  previous  treatment  in  any  given  case. 
In  several  cases  in  which  the  ossicles  had  been  removed  for 
caries,  and  the  discharge  had  ceased  completely,  the  patients 
returned  after  several  months  complaining  that  the  discharge 
had  reappeared.  This  was  found  to  be  due  to  the  develop- 
ment of  a  fungus  in  the  canal.  Thorough  cleansing  and  an 
application  of  a  solution  of  the  bichloride  of  mercury,  in  di- 
luted alcohol  in  the  proportion  of  i  to  2000,  destroys  such 
growths,  and  restores  the  parts  to  their  previously  quiescent 
condition. 

Where  the  discharge  depends  upon  the  lack  of  proper 
care  in  treating  a  previous  acute  catarrhal  inflammation,  we 
find  that  the  perforation  in  the  membrana  tympani  is  of  but 
small  size,  and  that  the  purulent  discharge  is  due  to  an  infec- 
tion of  the  normal  mucous  secretion  of  the  middle  ear.  After 
infection  the  fluid  products  are  but  imperfectly  evacuated, 
owing  to  the  narrowness  of  the  opening.  The  first  indication 
here  is  to  secure  free  drainage  by  enlarging  the  opening  with 
a  blunt  knife.  If  the  fluid  is  viscid,  it  is  frequently  wise  to 
make  two  diverging  incisions,  inclosing  a  V-shaped  flap,  to 
permit  the  complete  evacuation  of  the  contents  of  the  cavity 
upon  inflation  of  the  middle  ear.  After  thorough  cleansing — 
first  by  inflation,  and  subsequently  by  irrigation  of  the  tvm- 
panic  cavit}^  by  means  of  the  middle-ear  syringe  (shown  in 
Fig.  99),  and  thoroughly  disinfecting  the  meatus — these  cases 
may  recover  with  no  further  treatment.  If  this  does  not 
occur,  the  lining  of  the  tympanic  cavity  is  to  be  stimulated 
by  the  injection  of  a  mild  astringent  fluid,  introduced  by 
means  of  the  tympanic  syringe.  The  delicate  delivery  tube 
of  the  instrument  is  carried  through  the  perforation  and  a 
suflficient  quantity  injected  to  fill  the  t^-mpanum  completely. 
We  usually  recognize  the  fact  that  a  sufficient  amount  has 
been  injected  by  the  passage  of  the  fluid  through  the  Eusta- 
chian tube  into  the  pharynx.  We  should  never  begin  with  a 
solution  of  nitrate  of  silver  stronger  than  five  grains  to  the 
ounce  of  water,  subsequentl}^  increasing  the  strength  as  we 
find  the  parts  tolerant  to  the  drug.  Only  solutions  sterilized 
by  heat  should  be  used  in  this  manner,  and  the  instruments  em- 


TREATMENT   OF    DISCHARGE    FROM    MIDDLE    EAR.     409 

ployed  must  have  been  subjected  to  a  similar  process.  Where 
the  discharge  still  continues  in  spite  of  this  treatment,  and  no 
condition  is  present  in  the  nose  or  naso-pharvnx  which  would 
tend  to  aggravate  it,  good  results  may  often  be  obtained  by  ap- 
plying a  paper  dressing  to  the  part  after  the  middle  ear  has 
been  thoroughly  cleansed  and  the  mucous  membrane  subjected 
to  the  action  of  appropriate  drugs.  This  paper  dressing  was 
first  used  by  Blake,  and  consists  of  a  small  bit  of  thin  sized 
paper  of  appropriate  shape,  which  is  first  moistened  in  a  solu- 
tion of  bichloride  of  mercury,  i  to  1,000,  and  conveved  into 
the  middle  ear  by  the  forceps  or  upon  the  tip  of  the  cotton 
holder.  The  surface  of  this  disk  of  i)aper  is  applied  to  the 
drum  membrane,  and  by  manipulation  so  placed  as  to  occlude 
the  opening  in  it.  When  in  position,  its  edges  are  firmlv  but 
delicately  pressed  upon,  to  secure  close  contact  with  the 
drum  membrane  at  every  point.  The  efficiency  with  which 
this  has  been  done  can  be  demonstrated  bv  gentlv  inflating 
the  ear,  when  no  perforation  sound  will  be  heard  if  the  opera- 
tion has  been  satisfactorily  performed.  A  little  boric  acid  is 
now  lightly  dusted  over  the  disk  and  the  membrana  tvmj)ani. 
This  dressing  will  remain  in  jilace  for  a  j^eriod  varving  from 
four  davs  to  two  weeks,  at  the  end  of  which  time  it  will  prob- 
ably have  been  carried  toward  the  periphery  of  the  mem- 
brane, exposing  the  margin  of  the  perforation.  Another 
dressing  should  now  be  a[)plied  in  the  same  manner  as  before, 
overlapping  the  first  disk,  so  that,  as  the  exogenous  growth 
of  the  membrane  carries  the  first  outward,  the  opening  will 
be  graduallv  occluded  by  the  second  dressing.  The  stimula- 
tion which  the  presence  of  this  foreign  body  produces  is  fre- 
quently sufficient  to  effect  a  complete  closure  of  the  opening 
in  the  membrana  tvmpani,  while  its  protective  action  induces 
retrograde  changes  in  the  congested  lining  of  the  middle 
ear  after  securing  free  drainage  by  enlarging  the  opening. 
Where  a  sinus  leading  into  the  tympanic  vault  is  present 
immediately  beneath  either  the  anterior  or  posterior  fold,  it  is 
probable  that  the  osseous  structures  have  been  involved  by 
the  inflammatory  process.  If  we  do  not  detect  the  presence 
of  dead  bone  upon  examination,  the  treatment  detailed  in 
the  preceding  pages  may  be  followed  for  a  few  weeks ;  but, 
in  addition,  the  vault  of  the  cavity  should  be  irrigated  by 
means  of  the  tympanic  syringe,  the  delivery  tube  being  bent 
upward  at  its  extremity,  so  as  to  admit  of  insertion  into  the 


4IO  CHRONIC   PURULENT   OTITIS    MEDIA. 

sinus  and  injection  of  the  fluid  into  the  upper  spaces  (Fig. 
1 14).  Naturally  such  manipulation  can  only  be  carried  on  by 
the  surgeon  himself.  The  irrigation  should  be  repeated  at 
first  daily,  and  subsequently  less  frequently,  as  the  discharge 

diminishes  in  amount.  In 
cases  where  bony  necrosis 
has  taken  place  the  diseased 
bone  may  have  been  thrown 
off  spontaneously,  either  dis- 
integrating and  discharging 
in  the  form  of  pus,  or  it  may 
have  come  away  as  a  se- 
questrum at  some  former 
time. 

Here  the  persistence  of 
discharge  depends  upon  the 
retention   of    the   secretion 
in  the  reduplications  of  the 
Fig.  ii4.-lrriga^tion^o^^^^^^^^  vault   ^lucous  membranes  in    the 

vault  of  the  cavity.  It  is 
for  this  reason  we  are  warranted  in  attempting  at  first  to 
check  the  discharge  by  mild  measures.  Peroxide  of  hydro- 
gen, either  dilute  or  of  full  strength,  has  been  highly  recom- 
mended by  some  observers  for  the  irrigation  of  this  region ; 
aside  from  the  fact  that  the  antiseptic  action  of  this  drug  is 
visible,  I  see  no  reason  why  it  possesses  any  advantages  over 
other  solutions  which  are  known  to  destroy  pathogenic  bac- 
teria. Certainly  its  entrance  into  the  mastoid  cells  is  unde- 
sirable because  of  the  pressure  exerted  by  the  gas  evolved 
during  its  action. 

Failing  in  any  of  these  simpler  measures,  we  may  feel  cer- 
tain that  the  discharge  is  due  to  the  presence  of  diseased 
bone,  and  when  we  are  confident  of  this  fact  the  only  rational 
procedure  is  to  remove  it.  The  extent  to  which  the  bony 
structures  are  involved  influences  the  prognosis  materially  ; 
if  confined  to  the  ossicles  the  discharge  will  certainly  cease 
upon  ossiculectomy  and  thorough  curetting  of  the  tympanic 
walls.  If  the  process  is  so  extensive  as  to  involve  the  osse- 
ous walls  in  regions  inaccessible  to  instruments  introduced 
through  the  meatus,  the  removal  of  the  ossicles  may  still  be 
indicated  for  the  purpose  of  securing  free  drainage  of  the 
intratympanic  spaces,  although  the  discharge  may  not  entire- 


OPERATIVi:    PROCEDURES   FOR   OTORRHCEA. 


411 


ly  cease.  When  there  is  sagging  of  the  superior  wall  of  the 
canal,  a  history  of  previous  mastoid  symptoms  or  mastoid 
tenderness,  and  a  purulent  discharge  so  profuse  that  it  must 
originate  in  a  cavity  of  greater  size  than  the  middle  ear,  the 
ideal  procedure  is  an  external  operation,  completely  exposing 
the  pneumatic  spaces  of  the  mastoid,  together  with  the  walls 
of  the  tympanum.  Theoretically,  such  an  operation  should 
always  result  in  a  complete  cure.  Practically,  the  results 
obtained  up  to  the  present  time  are  hardly  better  than  those 
which  follow  the  removal  of  the  ossicles  and  a  curetting  of 
the  tympanum  and  adjacent  spaces  through  the  meatus.  The 
latter  procedure  does  not  confine  the  patient  to  the  house  for 
more  than  a  dav,  leaves  no  scar,  and  seems  less  formidable 
to  the  patient  than  does  the  procedure  bv  external  incision. 
The  technique  of  these  operations  is  considered  elsewhere. 

Operative  procedures  can  not  be  too  stronglv  urged  in  all 
cases  where  the  presence  of  diseased  bone  is  made  out  cither 
bv  tactile  examination  or  is  (juite  as  ceitaiiilv  indicated  by 
the  persistence  of  the  discharge  in  spite  of  aj)propriate  treat- 
ment. 

Regarding  the  efficacv  of  the  operation  of  excision  of  the 
ossicles  and  curettcment  of  the  tynipanum,  Ludewig*  rcj>ort- 
ed  forty-two  cures  in  seventy-five  cases  operated  upon.  Gru- 
nert  t  cited  thirteen  cures  in  twenty-eight  operations,  while 
the  author  +  reported  nearly  two  years  ago  fifteen  cures  in 
twenty-nine  cases  operated  upon,  while  in  nine  the  discharge 
was  greatly  reduced  in  quantity.  The  author's  later  opera- 
tions have  given  about  the  same  results.  Of  a  total  of  forty- 
two  cases,  twenty-three  have  been  cured,  while  thirteen  have 
been  much  improved.  In  the  remaining  six  cases  the  ultimate 
history  is  unknown,  although  in  all  but  two  there  was  con- 
siderable improvement  when  the  cases  were  last  seen.  In  the 
two  remaining  cases  the  patients  were  seen  but  once  after  the 
operation. 

So  far  we  have  considered  the  effect  of  treatment  upon  the 
discharge  alone.  Concerning  the  function  of  the  organ,  it  may 
be  said  that,  in  cases  of  extensive  destruction  of  the  membrana 


*  Arch,  fiir  Ohrenheilk.,  vol.  xxx,  p.  263. 
■f  Ibid.,  vol.  xxxiii,  p.  207. 

X  Supplement  to  Reference  Handbook  of  Medical  Sciences,  New  York.   1893, 
p.  244- 


412  CHRONIC   PURULENT    OTITIS    MEDIA. 

tympani  and  the  formation  of  adhesions  between  the  ossic- 
ula,  the  power  of  audition  may  diminish  slightly,  owing  to 
the  increased  tension,  after  the  parts  become  perfectly  dry. 
This  fact  does  not  render  the  necessity  or  advisability  of  stop- 
ping the  discharge  less  imperative,  since  any  resulting  impail'- 
ment  of  function  can  be  corrected  by  division  of  the  adhesions 
at  a  subsequent  period,  while  the  continued  secretion  of  pus 
is  a  constant  menace  to  life.  Following  surgical  procedures, 
the  function  of  the  organ  is  usually  improved  where  the  hear- 
ing is  considerably  impaired  before  the  operation.  Where 
the  hearing  is  but  slightly  impaired  we  need  not  fear  that  it 
will  be  reduced  by  the  operative  measures  proposed.  Lude- 
wig  *  reports  a  slight  impairment  of  the  hearing  as  a  result  of 
the  operation  in  six  cases  out  of  seventy-five  operated  upon. 
In  my  own  cases  but  one  instance  of  this  kind  has  occurred  in 
fifty  operations.  Impairment  of  the  function  more  frequently 
follows  the  cessation  of  the  discharge  from  treatment  with 
astringents  or  caustics  than  from  the  method  now  under  con- 
sideration. We  assume  here  that  the  impairment  in  function 
is  due  principallv  to  the  intratympanic  lesion  and  not  to  any 
labyrinthine  involvement.  Extensive  involvement  of  the  laby- 
rinth would  contraindicate  an  operation  for  the  improvement 
of  hearing  alone,  but  should  scarcely  stand  in  the  way  of  the 
procedure  for  the  relief  of  the  discharge.  The  relief  of  sub- 
jective noises  can  very  rarely  be  promised  from  any  form 
of  treatment,  although  where  the  mucous  membrane  is  verv 
much  congested  we  should  hope  to  abate  their  intensity  as 
we  reduce  the  turgesccnce.  It  is  never  safe  to  promise  re- 
lief from  this  symptom  by  operative  measures.  On  the  other 
hand,  these  last-named  procedures  seldom  or  never  produce 
subjective  noises. 

The  changes  which  take  place  in  the  tympanic  mucous 
membrane  after  the  removal  of  the  ossicles  and  of  the  rem- 
nant of  the  membrana  tympani  var}'-  considerably  in  differ- 
ent cases.  The  most  favorable  change  is  one  in  which  the 
mucous  membrane  gradually  undergoes  dermoid  transfor- 
mation. If  this  occurs,  the  membrane  no  longer  secretes, 
and  the  patient  is  not  liable  to  recurrent  attacks  of  dis- 
charge from  the  ear  whenever  the  upper  air  tract  becomes 
acutely    inflamed.      In    children    this    transformation    takes 

*  Arch,  fiir  Ohrenheilk.,  vol.  xxx,  p.  263. 


TREATMENT    OF    OTORRHCEA    AFTER    OPERATION. 


413 


place  onlv  after  a  long-  period,  but  in  adults  \vc  may  hope 
for  it  in  from  eight  to  ten  months  after  the  operation.  Cer- 
tain steps  at  the  time  of  the  operation  may  hasten  this  trans- 
formation. Thus,  if  a  small  segment  of  the  membrana  tym- 
pani  is  allowed  to  remain  at  the  lower  part,  and  the  mucous 
membrane  over  the  promontory  immediately  opposite  this 
segment  is  denuded  by  means  of  the  curette,  this  small  flap 
will  apply  itself  to  the  denuded  surface  and  rapidl}'  become 
attached.  The  superficial  epithelium  spreads  over  the  wall 
of  the  middle  ear,  transforming  it  into  a  nonsccreting  sur- 
face. Where  the  mucous  membrane  remains  intact,  even  al- 
though our  procedure  mav  have  stopped  the  discharge  pcr- 
manentlv,  we  should  remember  that  anv  severe  congestion  or 
inflammation  of  the  upper  air  tract,  such  as  a  severe  cold  in 
the  head,  mav  produce  a  tcmf)()rarv  otorrh(jea ;  this  will  usu- 
ally subside  spontaneously  when  the  exciting  cause  has  dis- 
appeared. In  order  that  this  mav  haj)j>cn.  the  canal  must  be 
kept  free  from  anv  infection  while  the  discharge  lasts.  This 
end  mav  be  attained  by  cleansing  the  canal  with  the  syringe 
twice  daily.  The  solution  to  be  employed  should  be  of  a 
mild  antiseptic  character.  A  solution  of  bichloride  of  mer- 
cury (i  to  8,000)  answers  the  purpose  admirably.  After  irri- 
gation the  patient  should  instil  a  few  drops  of  an  alcoholic 
solution  of  boric  acid  (gr.  xx  to  5j)  or  of  bichloride  of  mer- 
cury (i  to  3.000)  into  the  car. 

If  the  discharge  is  but  slight  and  the  jiaticnt  is  seen  daily 
it  may  be  sufficient  to  dry  the  parts  thoroughly  with  cotton 
and  then  apply  one  of  the  alcoholic  solutions  above  men- 
tioned to  the  walls  of  the  meatus  and  middle  ear  with  the 
cotton  applicator.  If  these  measures  are  carefully  carried 
out  the  discharge  will  cease  in  a  few  days.  A  condition 
which  we  may  sometimes  be  called  upon  to  combat  by  oper- 
ative interference  is  where  this  dermoid  transformation  takes 
place  spontaneously  in  cases  which  have  not  been  subjected 
to  treatment.  Where  a  small  perforation  is  present  in  the 
upper  portion  of  the  drum  membrane  the  epithelium  of  its 
outer  surface  occasionally  grows  into  the  tympanic  cavity, 
where  it  proliferates,  lining  the  entire  vault  with  c{)idermis. 
Owing  to  the  increased  vascularity  of  the  part,  this  new  lin- 
ing membrane  becomes  the  seat  of  a  desquamative  inflamma- 
tion, superficial  cells  being  produced  and  thrown  off  more 
rapidly  than  under  normal  conditions.     The  cavity  becomes 


414  CHRONIC    PURULENT    OTITIS    MEDIA. 

filled  with  desquamated  epithelial  cells,  and  exactly  the  same 
result  follows  as  when  a  similar  condition  is  present  in  the 
external  meatus.  The  bony  walls  of  the  cavity  are  absorbed, 
and  at  the  same  time  undergo  consolidation  as  the  result  of 
chronic  osteitis.  An  acute  inflammation  in  an  organ  thus 
affected  causes  a  sudden  augmentation  in  the  volume  of 
this  epithelial  mass,  and  increases  the  pressure  upon  the  sur- 
roundino-  walls.  Sometimes  the  process  is  so  insidious  that 
the  patient  may  not  be  cognizant  of  morbid  changes  in  the 
ear  until  these  symptoms,  due  to  the  sudden  change,  su- 
pervene, and  the  surgeon  may  first  be  consulted  when  oper- 
ative measures  alone  will  relieve  the  case.  The  problem 
which  we  have  to  solve  in  such  an  event  is  whether  we  shall 
relieve  the  symptoms  by  an  operation  through  the  canal, 
or  whether  it  is  necessary  to  open  the  mastoid.  Experience 
shows  that  the  changes  may  be  confined  to  the  vault  of  the 
tympanum.  In  recent  cases,  and  where  no  marked  mastoid 
symptoms  exist,  such  as  external  tenderness,  pronounced  and 
extensive  sinking  of  the  posterior  wall  of  the  canal,  and  spon- 
taneous pain  over  the  mastoid,  I  am  inclined  to  prefer  clear- 
ing out  the  vault  of  the  tympanum  through  the  canal  as  a 
primary  procedure.  Frequently  this  is  sufficient,  and  entire 
relief  to  the  pressure  symptoms  follows,  while  at  the  same 
time  the  purulent  condition  is  permanently  arrested.  When 
the  process  has  invaded  the  mastoid,  any  operative  procedure 
must  not  only  remove  the  accumulation  within  the  cells,  but 
must  also  place  these  pneumatic  spaces  in  communication 
with  the  meatus,  in  order  that  subsequent  trouble  may  be 
avoided.  From  the  nature  of  the  pathological  condition  it 
may  be  practically  impossible  to  extirpate  every  vestige  of 
the  lining  membrane  which  has  undergone  dermoid  trans- 
formation, and  a  recurrence  may  take  place.  It  is  our  duty 
to  establish  a  condition  which  will  enable  any  subsequent 
accumulation  to  be  removed  without  a  severe  operation.  To 
effect  this  the  mastoid  is  opened  in  the  usual  way,  and  the 
cell  structure  obliterated  by  means  of  the  curette,  after  which 
the  dividing  wall  between  the  artificial  opening  and  the  me- 
atus is  taken  away,  throwing  the  mastoid  cells  and  external 
canal  into  one  cavity.  The  posterior  wall  of  the  fibrous  canal 
is  divided  longitudinally,  and  the  two  flaps  thus  formed  turned 
back  into  the  bony  cavity  and  retained  in  position  by  a  tam- 
pon of  gauze.      Any   subsequent  accumulation   can    now   be 


THERAPEUTIC    MEASURES    IN    OTORRHCEA. 


415 


removed  in  the  manner  ordinarily  employed  in  dealing  with 
desquamative  external  otitis. 

We  have  limited  ourselves  to  local  measures  in  consider- 
ing the  treatment.  In  patients  of  a  lymphatic  habit,  particu- 
larly in  children,  much  benefit  will  be  gained  by  the  internal 
administration  of  iodide  of  iron  in  full  doses.  Where  evi- 
dences of  malnutrition  exist  as  the  result  of  some  hereditary 
diathesis  the  exhibition  of  cod-liver  oil  and  of  the  hypo- 
phosphites  will  be  found  beneficial.  In  the  adult  attention 
should  be  given  to  regulating  the  habits  of  life  so  as  to  dimin- 
ish the  tendency  to  congestion  in  the  upper  air  tract  as  much 
as  possible.  The  use  of  alcohol,  and  in  certain  cases  of  to- 
bacco, is  particularly  to  be  interdicted,  although  the  influence 
of  the  latter  is  comparatively  slight. 


CHAPTER   XXIII. 

OTITIS    MEDIA   PURULENTA    RESIDUA. 

By  this  term  we  designate  that  class  of  cases  in  which  a 
former  purulent  inflammation  has  resulted  in  a  permanent 
destruction  of  certain  of  the  tympanic  structures.  Either 
spontaneously  or  as  the  result  of  treatment,  the  discharge  has 
ceased,  and  we  are  called  upon  to  relieve  symptoms  due 
either  to  the  adhesions  which  have  developed  within  the 
tympanum  or  to  certain  changes  which  have  resulted  from 
the  purulent  inflammation.  For  convenience  we  divide  these 
cases  into  two  classes  : 

1.  Where  the  symptoms  are  acute  or  subacute. 

2.  Where  the  symptoms  are  of  a  chronic  character. 

I.  Acute  Cases. 

.Etiology. — The  underlying  cause  in  these  cases  is  evident 
from  the  title  applied.  As  an  exciting  cause  we  may  have 
any  of  those  operative  in  the  production  of  the  various  varie- 
ties of  acute  inflammation,  but  we  usually  find  an  acute  in- 
flammation of  the  upper  air  tract,  either  a  simple  coryza,  an 
acute  naso-pharyngitis,  or  an  influenza  of  the  epidemic  char- 
acter. Among  other  exciting  causes  we  must  bear  in  mind 
those  which  operate  through  the  external  meatus,  such  as  the 
insertion  of  an}^  device  into  the  canal  for  cleansing  the  ear, 
blows  upon  the  auricle,  and  the  development  within  the 
tympanum  of  some  of  the  vegetable  molds. 

Pathology. — The  changes  which  take  place  vary  widely 
according  to  the  condition  in  which  the  previous  inflamma- 
tory process  has  left  the  parts.  Cases  in  which  the  mem- 
brana  tympani  has  been  almost  completely  destroyed,  expos- 
ing a  large  area  of  the  inner  wall  of  the  middle  ear,  present 
generally  a  simple  venous  h3-pera3mia  of  this  membrane,  re- 
sulting in  oedema,  and  subsequently  in  serous  transudation. 
The  condition  found  here  is  similar  to  that  described  under 

(416) 


PATHOLOGY    AND    SYMPTOMATOLOGY.  ajj 

acute  catarrhal  otitis  media,  or  tubo-tvmpanic  congestion  oc- 
curring in  an  organ  in  which  the  niembrana  tympani  is  in- 
tact. In  the  cases  under  consideration  the  serous  transuda- 
tion, which  results  from  the  inflammatory  process,  appears  in 
the  external  auditory  meatus  as  a  discharge,  for  the  reason 
simply  that  the  opening  in  the  drum  membrane  allows  it  to 
escape  from  the  tympanic  cavity.  Where  the  membrana 
tympani  is  intact  the  same  transudation  collects  within  the 
middle  ear.  It  is  a  matter  of  some  importance  to  remember 
this,  as  such  a  discharge  does  not  become  purulent  unless 
infected  from  without.  If  the  external  meatus  is  kept  in  a 
thoroughly  aseptic  condition,  the  disease  is  self-limited  and 
the  discharge  ceases  spontaneously  at  the  end  of  a  few  days. 
On  the  other  hand,  if  infection  occur,  a  chronic  purulent 
otitis  may  result.  The  remaining  jiortion  of  the  membrana 
tympani  is  affected,  becoming  hypera-mic,  desquamating  if 
the  process  is  pronounced,  and  increasing  in  thickness. 
Where  the  upper  portion  of  the  drum  membrane  remains, 
and  the  intratympanic  folds  has  become  much  thickened 
by  the  development  of  new  connective  tissue,  these  lamellae 
increase  in  volume,  and  may  completely  fill  the  vault.  If  this 
portion  of  the  cavity  is  completely  shut  off  from  the  atrium 
the  subsequent  transudation  causes  a  bulging  of  the  mem- 
brana flaccida,  wiiich  may  {)rotrude  into  the  canal  so  as  to 
resemble  closely  a  mass  of  granulation  tissue.  From  the 
changes  which  have  taken  place  it  is  usually  so  dense  that  the 
fluid  inclosed  can  not  esca[)e  bv  spontaneous  rupture.  The 
case  then  presents  the  characteristics  of  a  primary  acute  pu- 
rulent inflammation  of  the  middle  ear,  with  the  exception 
that  the  osseous  walls  become  involved  more  quickly  than 
when  the  affection  is  primary.  Destruction  either  of  some 
part  of  the  ossicular  chain  or  of  the  surrounding  tympanic 
walls  results,  and  with  a  subsidence  of  the  acute  symptoms  a 
chronic  purulent  otitis  remains.  When  cholesteatomatous 
changes  have  taken  place  the  involvement  either  of  the  mas- 
toid cells  or  of  the  cranial  cavity  itself  is  exceedingly  prone 
to  occur. 

Symptomatology. — In  the  cases  in  which  the  membrana 
tympani  is  destroyed  over  a  large  area,  the  symptoms  consist 
of  a  slight  impairment  of  the  hearing,  occasionally  with  the 
development  of  subjective  noises.  The  prominent  feature, 
however,   is   the   appearance   of    a    discharge  from    the    ear. 


4i8  OTITIS    MEDIA    PURULENTA    RESIDUA. 

This  class  of  cases  occurs  most  frequently  in  children  of  from 
eight  to  twelve  years  of  age,  in  whom  the  chronic  purulent 
otitis  has  followed  one  of  the  exanthemata  in  early  life.  Pain 
is  not  a  prominent  symptom  as  a  rule,  and  were  it  not  for  the 
appearance  of  the  discharge  the  attack  would  probabl}-  pass 
unnoticed.  Occasionally  we  may  have  developed  in  the  ex- 
ternal canal  an  area  of  circumscribed  inflammation  due  to 
local  infection  ;  when  this  occurs  there  is  intense  pain.  In 
the  cases  in  which  the  upper  part  of  the  cavity  is  affected  the 
pain  is  severe,  prostration  well  marked,  the  temperature  is 
elevated  from  one  to  four  degrees,  and  there  may  be  no  dis- 
charge, or,  if  present,  it  is  usually  scanty.  The  pain  may  be 
localized  in  the  ear  or  may  spread  to  the  entire  temporal 
region. 

The  occurrence  of  facial  paralysis  very  early  in  the  attack 
is  not  infrequent.  The  function  of  the  organ  may  be  but 
slightly  impaired,  owing  to  the  location  of  the  affected  area. 

Diagnosis. — The  result  of  functional  examination  depends 
so  much  upon  the  previous  condition  that  it  need  not  be 
considered,  acute  symptoms  alone  demanding  attention. 

Physical  Examination. — Upon  inspection,  where  we  find 
that  the  destruction  of  the  drum  membrane  has  been  exten- 
sive, the  exposed  lining  of  the  tympanum  is  red,  velvety  in 
appearance,  and  coated  either  with  a  colorless  watery  dis- 
charge, or,  at  a  later  period  this  is  opaque  in  character. 
The  remnant  of  the  drum  membrane  is  thickened,  turgescent, 
and  oedematous.  When  examined  before  the  process  is  far 
advanced,  it  may  present  a  dead-white  appearance,  owing  to 
a  necrosis  of  the  superficial  layer  of  its  epithelium.  Removal 
of  this  epithelial  covering  reveals  a  turgidity  of  the  underlying 
parts.  Where  the  upper  segment  of  the  cavity  is  involved, 
the  remnant  of  the  drum  membrane  is  intensely  congested, 
thickened,  and,  together  with  the  adjacent  canal  wall,  bulges 
into  the  lumen  of  the  passage,  narrowing  the  fundus  to  so 
marked  a  degree  as  completely  to  fill  the  inner  extremity  of 
the  canal  in  some  cases  and  prevent  an  inspection  of  the  re- 
gion of  the  atrium.  This  obstructing  mass  may  be  movable 
upon  manipulation  with  the  probe,  and  present  many  of  the 
characteristics  of  granulation  tissue.  Impact  with  the  probe 
shows  that  it  is  too  firm  and  dense  for  granulation  tissue.  It 
does  not  bleed  easily  when  touched,  and,  although  movable, 
its  attachment  is  broad.     Careful  inspection  will   usually  en- 


DIAC'.N'OSIS    AND    PROGNOSIS.  ^IC) 

able  us  to  make  out  that  its  surface  is  continuous  with  the 
supero-posterior  canal  wall,  thus  establishing  its  identity.  The 
mass  is  exquisitclv  tender  to  pressure.  \"ery  little  discharge 
is  present,  but  the  surface  of  the  drum  membrane  and  the  ad- 
jacent walls  of  the  canal  arc  the  seat  of  a  desquamative  pro- 
cess, and  upon  removing  the  epithelium,  considerable  serous 
transudation  mav  take  place,  rendering  exact  diagnosis  diffi- 
^  cult.  Inflation  with  the  catheter  or  air  bag  reveals  no  per- 
foration sound,  the  impact  of  the  current  being  perceived  as 
a  dull,  distant  percussion  sound,  occasionally  accompanied  by 
bubbling  rales.  The  conditions  with  which  this  may  be  con- 
founded are  the  presence  of  exuberant  granidations,  from 
which  we  have  already  given  the  means  of  difTcrentiation,  and 
a  circumscribed  external  otitis.  This  latter  condition,  we 
remember,  usually  affects  the  fibro-cartilaginous  meatus,  and 
after  the  speculum  has  once  passed  the  orifice  of  the  canal, 
the  lumen  apj)ears  of  normal  size.  It  may  occasionally  be 
mistaken  for  a  diffuse  external  otitis,  but  here  the  canal  is 
uniformly  narrowed,  the  deeper  portion  of  the  postero-suj)e- 
rior  wall  being  affected  no  more  prominently  than  its  entire 
length.  Tenderness  over  the  mastoiil  region  denotes  an  in- 
volvement of  the  pneumatic  Sjiaces,  but  a  much  better  sign  is 
the  appearance  already  described  in  the  canal.  When,  there- 
fore, the  appearance  is  indicative  of  a  circumscribetl  otitis  of 
the  deep  canal,  we  are  to  remember  that  this  condition  is 
almost  pathognomonic  of  mastoid  involvement,  and  are  to 
proceed  to  treat  the  mastoid   inflammation  without  delay. 

Prognosis. — The  cases  in  which  discharge  alone  is  the 
symptom  almost  invariably  terminate  favorably,  often  without 
treatment.  If  neglected,  infection  may  take  place,  and  a 
chronic  purulent  condition  suj^ervene.  The  occurrence  of 
one  attack  probably  renders  the  patient  more  prone  to  a  simi- 
lar process  in  future.  In  the  cases  attended  by  pain  the 
condition  is  practically  one  of  cellulitis,  and  should  never  be 
considered  lightly.  If  left  to  itself,  it  may  resolve  spontane- 
ously, or  the  fluid  may  escape  into  the  atrium  and  then  into 
the  canal,  or  rupture  may  take  place  through  the  superior 
segment  of  the  drum  membrane.  If  spontaneous  resolution 
does  not  take  place,  evacuation  in  either  manner  mentioned 
above  seldom  occurs  before  the  bony  parts  are  seriously  in- 
volved, and  a  permanent  discharge  is  a  frequent  outcome. 
If  discharge  does  not  take  place,  involvement  of  the  mastoid 


420  OTITIS    MEDIA    PURULENTA    RESIDUA. 

cells  or  an  extension  to  the  intracranial  contents,  either  by 
rupture  or  by  infection  through  the  venous  channels,  may 
occur.  Concerning  the  effect  upon  audition,  there  is.  little 
danger  that  the  function  of  the  organ  will  be  changed  by  such 
an  intercurrent  attack,  the  degree  of  impairment  which  was 
formerly  present  persisting  but  suffering  no  aggravation. 

Treatment. — For  the  relief  of  the  discharge,  attention  to 
cleanliness  is  all  that  is  necessary.  Irrigation  with  a  mild 
solution  of  any  of  the  well-known  antiseptics,  repeated  as 
frequently  as  may  be  necessary  to  keep  the  canal  free  of  dis- 
charge, is  usually  the  only  treatment  required.  This  measure, 
in  addition  to  cleansing  the  parts,  causes  a  certain  amount  of 
depletion,  which  hastens  resolution.  In  order  that  no  secre- 
tion mav  remain  in  the  middle  ear,  it  is  well  to  inflate  by 
means  of  the  air  bag  or  bv  the  Valsalva  method  before  irriga- 
tion. In  the  early  stages  remedies  directed  toward  stopping 
the  discharge  are  contraindicated.  When  the  more  acute 
symptoms  have  passed  away,  if  the  discharge  continues,  we 
may  follow  each  irrigation  by  the  instillation  of  a  solution  of 
boric  acid  in  alcohol  in  the  proportion  of  twenty  grains  to 
the  ounce,  or  a  i-to-3,000  solution  of  the  bichloride  of  mercury 
dissolved  in  equal  parts  of  alcohol,  and  water  may  be  em- 
ployed in  the  same  manner.  Occasional  applications  of  me- 
tallic astringents — such  as  solutions  of  nitrate  of  silver,  from 
two  to  twelve  per  cent — will  frequently  hasten  the  return  to 
the  normal  condition.  Where  the  discharge  is  small  in 
amount  but  fails  to  cease  entirely,  we  may  discontinue  irri- 
gation altogether  and  rely  upon  insufflation  of  powders.  Of 
these,  nothing  is  better  than  boric  acid,  either  alone  or  with 
the  addition  of  iodoform,  alum,  iodol,  etc.  In  making  appli- 
cations of  this  character,  but  a  small  quantity  of  the  powder 
should  be  used,  to  avoid  mechanical  obstruction  to  any  fluid 
which  may  be  transuded. 

If,  in  spite  of  intelligent  treatment,  the  discharge  contin- 
ues, we  are  warranted  in  the  supposition  that  the  osseous 
structures  have  become  involved,  and  relief  will  follow  only 
the  removal  of  the  diseased  bone.  To  guard  against  recur- 
rent attacks,  attention  to  the  upper  air  passages  is  of  the 
greatest  importance.  These  recurrent  cases  usually  occur  in 
children  under  fifteen  years  of  age,  and  in  many  instances  we 
find  that  the  vault  of  the  pharynx  contains  an  excessive 
amount    of    Ivmphatic  tissue,   while   the  faucial   tonsils    may 


TREATMENT. 


421 


also  be  hypcrtrophied.  These  conditions  call  for  operative 
treatment,  or  topical  applications,  as  may  seem  best  adapted 
to  the  particular  case.  Any  obstructive  lesion  in  the  nasal 
passages  must  also  be  overcome  by  operative  or  other 
methods. 

Where  the  upper  portion  of  the  tvmpanic  cavitv  is  the 
seat  of  the  process,  the  first  indication  is  to  relieve  the  pain, 
and  at  the  same  time  to  abort  the  local  condition  ;  or,  if  too 
far  advanced  for  this,  to  evacuate  the  products  of  inflamma- 
tion. To  effect  the  first  object,  the  patient  should  be  put  to 
bed  and  a  full  dose  of  opium  or  morphine  administered,  while 
at  the  same  time  local  depletion  should  be  employed.  Un- 
doubtedly the  best  method  of  attaining  this  end  is  a  free  in- 
cision through  the  ujipcr  part  of  the  mcmbrana  tympani 
behind  the  short  process  of  the  malleus.  This  incision  should 
extend  from  the  last-named  point  backward  to  the  canal  wall, 
and  may  be  continued  outward  upon  its  surface  for  from  a 
sixteenth  to  a  quarter  of  an  inch  ;  this  I  believe  should  be 
done  whether  anv  bulging  is  present  or  not.  If  fluid  has  al- 
ready been  effused  and  there  are  evidences  of  obstruction  to 
its  free  discharge,  the  i)r()cedurc  is  imperatively  demanded. 
If  this  stage  has  not  been  reached,  the  local  dejiletion  will 
probably  check  its  progress.  If  it  does  not  seem  advisable 
to  incise  the  parts,  the  application  (jf  natural  leeches  or  of 
the  artificial  leech  in  front  of  the  tragus,  removing  from  one 
to  two  ounces  of  blood,  according  to  the  age  and  condition 
of  the  patient,  is  the  procedure  to  be  employed.  The  appli- 
cation of  cold  to  the  mastoid  is  proper  if  there  is  the  least 
suggestion  of  swelling  along  the  posterior  wall  of  the  canal ; 
irrigation  of  the  parts  with  warm  aseptic  or  antiseptic  solu- 
tions should  be  begun  at  once,  whether  an  incision  has  been 
made  or  not.  If  this  has  been  done  it  will  favor  the  ha^^mor- 
rhage  and  render  our  efforts  at  aborting  the  attack  more  cer- 
tain, while  if  no  surgical  measures  have  been  instituted  the 
combined  effect  of  heat  and  moisture  may  so  reduce  the 
tumefaction  as  to  permit  the  discharge  of  the  fluid  products 
through  the  atrium,  or  may  possibly  lead  to  resolution  with- 
out the  supervention  of  discharge.  The  internal  adminis- 
tration of  analgesics  is  contraindicated  after  the  first  twent}'. 
four  or  thirty-six  hours,  as  it  serves  only  to  mask  the  symp- 
toms. If  relief  is  not  obtained  at  the  end  of  this  time,  and 
surgical  measures  have  been  delayed,  they  must  now  be  in- 


422  OTITIS    MEDIA    PURULENTA    RESIDUA. 

sisted  upon,  and  a  free  section  of  the  tissues  involved  must 
be  made.  The  use  of  the  ice  coil  should  not  be  persisted  in 
for  more  than  forty-eight  hours  ;  if,  in  spite  of  its  use,  the 
pain  continues  severe  and  the  mastoid  is  tender  upon  pres- 
sure, or  even  if  there  is  no  tenderness,  if  the  postero-superior 
wall  is  depressed,  the  process  has  almost  certainly  extended 
to  the  pneumatic  spaces  of  this  structure,  and  operation 
should  not  be  delayed.  Regarding  the  value  of  Wilde's  in- 
cision in  these  cases,  I  can  only  say  that  1  never  employ  the 
measure.  If  the  symptoms  do  not  seem  prominent  enough 
to  warrant  the  opening  of  the  mastoid,  incision  of  the  over- 
lying parts  on  its  anterior  surface,  which  forms  the  posterior 
and  superior  walls  of  the  meatus,  is  the  measure  which  will 
most  probably  give  relief.  It  certainly  possesses  all  the  bene- 
fits of  the  external  incision,  both  as  regards  the  relief  of  ten- 
sion and  depletion,  and  may  very  properly  be  emplo3'ed  as  a 
last  resort  before  opening  the  mastoid  process.  In  this  class 
of  cases  I  think  we  can  not  too  stronglv  insist  upon  an  early 
mastoid  operation  if  the  symptoms  do  not  disappear  promptly. 
The  advantages  of  this  are  not  only  the  immediate  relief  to 
the  present  condition,  but  also  the  certainty  with  which  a 
subsequent  chronic  purulent  otitis  media  is  prevented.  Un- 
less checked  by  radical  measures,  the  affection  is  almost  cer- 
tain to  be  followed  by  a  chronic  otorrhoca,  although  the  pres- 
ent attack  ma}^  be  recovered  from.  Where  an  operation  is 
performed  carlv  we  usually  avoid  this,  and  the  period  of  con- 
valescence is  much  shortened.  Another  advantage  is  that 
recurrence  is  decidedlv  uncommon  in  cases  operated  upon, 
whereas  those  cases  which  recover  without  operation  are 
specially  prone  to  recurrence  of  the  condition.  Operations 
to  obtain  drainage  through  the  meatus  can  not  be  advised  ; 
no  doubt  in  some  instances  they  are  successful,  but  the  en- 
gorgement of  the  parts  is  so  great  that  the  haemorrhage  must 
be  considerable,  and  in  the  narrow  field  of  operation  this  pre- 
sents an  almost  insurmountable  obstacle. 

2.  Chronic  Type. 

Under  this  term  is  comprised  those  cases  whose  symp- 
toms depend  upon  the  changes  which  have  taken  place  as  the 
result  of  persistent  inflammation.  These  either  remain  con- 
stant or  increase  very  slowly,  according  as  the  connective 
tissue  developed  as  a  result  of  the  pathological  condition  is 


CHRONIC    TYPE:    ITS    PATHOLOGY. 


423 


in  a  perfectly  (luiescent  condition,  or  is  slowly  undergoing 
secondary  sclerotic  changes.  The  condition  is  comprised 
under  the  general  term  "  rigidity  of  the  ossicular  chain,"  and 
the  afifection  is  by  some  authors  denominated  as  "  otitis  media 
sclerotica."  Owing  to  the  increase  in  fibrous  tissue  within 
the  middle  ear,  the  entire  ossicular  chain  is  carried  inward 
toward  the  internal  wall ;  the  foot  plate  of  the  staj)cs  is 
crowded  into  the  ovaI  window,  causing  an  increase  in  laby- 
rinthine pressure,  while  at  the  same  time  the  outward  moye- 
ment  of  the  membrana  tympani  secondaria  is  inij^edcd 
through  a  process  of  a  similar  character  in  this  region.  We 
have,  then,  the  labyrinthine  fluid  subjected  to  a  permanent 
increase  in  pressure.  No  doubt  the  equilibrium  is  partially 
restored  by  the  passage  of  the  Huid  through  the  channels 
communicating  with  the  subdural  Ivmph  sjxaces.  Where  the 
increase  of  pressure  is  but  moderate  in  amount  this  may  so 
far  compensate  for  the  inward  movement  of  the  stapes  as  to 
render  the  condition  of  equilibrium  j>ractically  j^erfcct,  in 
which  case  no  symptoms  arise.  More  frequently  the  in- 
creased tension  persists,  producing  in  the  early  stages  the 
symptoms  characteristic  of  acute  labyrinthine  pressure,  while 
at  a  later  period  evidences  of  atrophy  of  the  terminal  fila- 
ments of  the  auditory  nerve  manifest  themselves,  the  con- 
tinued pressure  destroying  these  structures. 

Pathology. — Following  the  same  general  classification  of 
gross  jiathological  appearances  already  described  in  treating 
of  chronic  juirulent  otitis  media,  it  is  not  difficult  to  under- 
stand how  in  each  individual  class  the  action  of  the  conduct- 
ing chain  in  response  to  aerial  vibrations  is  seriously  inter- 
fered with.  We  may  classify  the  interference  with  sound 
transmission  in  these  cases  as  due  to — 

1.  Simple  oedema  of  the  mucous  membrane. 

2.  The  presence  of  localized  areas  of  h3-pertrophy  due  to 
chronic  inflammation. 

3.  Adhesions  either  between  the  various  members  of  the 
ossicular  chain  or  between  the  malleus  and  incus  and  the  in- 
ternal tympanic  wall. 

4.  Cicatricial  bands  in  the  membrana  tympani.  The  mem- 
brana tympani  itself  may,  as  the  result  of  a  chronic  inflam- 
mation, press  the  entire  ossicular  chain  inward.  This  is  spe- 
cially true  of  cases  in  which  a  large  portion  of  the  membrane 
has  been  destroyed  and  the  margin  of  the  perforation  coin- 


424 


OTITIS    MEDIA    PURULENTA    RESIDUA. 


cides  with  the  posterior  fold.  A  dense  band  frequently  de- 
velops here,  which  crowds  either  the  stapes  or  incus  inward, 
causing  serious  impairment  of  function. 

5  Adhesions  limited  to  the  region  of  the  stapes.  These 
adhesions  develop  either  between  the  foot  plate  and  the  oval 
window,  or  between  the  crura  and  the  walls  of  the  pelvis 
ovalis,  or  from  dense  bands  about  the  tendon  of  the  stapedius 
muscle. 

This  classification,  it  is  understood,  is  merely  general;  any 
of  the  conditions  may  exist  singly,  or  several  may  be  pres- 
ent in  the  same  case.  In  general  it  may  be  said  that  the  im- 
pairment in  hearing  and  tinnitus  undergo  but  little  change 
in  those  cases  where  the  functional  disturbance  is  due  to  a 
deposit  of  new  connective  tissue  either  in  the  remnant  of  the 
membrana  tympani  or  between  the  various  ossicula  them- 
selves, or  between  the  ossicles  and  the  tympanic  walls. 
Where  the  drum  membrane  is  destroyed  over  a  large  area 
and  the  lining  of  the  tympanic  cavity  is  exposed,  the  power 
of  audition  frequently  varies  considerably  at  different  times. 
Such  changes  usually  depend  upon  congestion  of  the  lining 
of  the  middle  ear,  or  upon  an  accumulation  of  inspissated 
secretion   in   the   deeper  portions  of  the   canal.     In  many  of 

these  cases,  although  there  is 
apparently  no  discharge,  the  mu- 
cous membrane  has  not  under- 
gone complete  dermoid  trans- 
formation, and  consequently 
continues  to  pour  out  a  small 
amount  of  secretion.  This  be- 
comes inspissated  and  collects 
most  frequently  in  the  upper 
and  posterior  quadrant  directly 
over  the  stapes,  and  sometimes 
seriously  interferes  with  the 
movements  of  the  ossicle  (Fig. 
115).  Those  cases  which  suffer 
from    frequently    recurring    at- 


tacks of  congestion  of  the  lining 


Fk;.  115. — Inspissated  secretion  mixed 
with  cerumen,  covering  a  small 
perforation  in  the  supero-posterior 
quadrant  (natural  sire). 

membrane  of  the  middle  ear 
with  the  production  of  a  slight  amount  of  discharge  are  prone 
to  suffer  from  the  development  of  exuberant  granulations  in 
the  various  portions  of  the  tympanic  cavity.     This  is  particu- 


SYMPTOMATOLOGY. 


425 


larly  true  where  proper  attention  is  not  paid  to  cleanliness, 
the  continued  action  of  heat  and  moisture  favoring  the  devel- 
opment of  exuberant  granulations. 

Symptomatology. — The  symptoms  to  which  these  changes 
give  rise  consist  usually  in  an  impairment  of  function  of  the 
organ,  either  to  a  considerable  extent  or  only  to  a  slight  de- 
gree. As  we  have  said  before,  impairment  in  hearing  follow- 
ing purulent  inflammation  is  less  marked  than  when  it  occurs 
as  the  result  of  a  nonsuppurative  inflammation.  The  pres- 
ence of  subjective  noises  is  not  a  symptom  of  as  much  im- 
portance in  these  cases,  as  they  are  seldom  so  prominent  as 
to  give  serious  discomfort,  and  unless  specially  inquired  into 
mav  not  be  mentioned  by  the  patient  himself.  Attacks  of 
giddiness  are  occasionallv  complained  of.  usuallv  following 
some  manipulation  about  the  ear,  such  as  the  insertion  of 
some  instrument  into  the  canal  for  cleansing  it,  or  the  use  of 
the  syringe.  In  these  instances  we  usuallv  find  that  the  head 
of  the  stapes  is  exposed.  From  the  above  classification  of 
the  affection  we  are  now  considering  no  discharge  is  {)rcscnt 
in  these  cases.  The  canal,  however,  is  seldom  perfectly  free 
from  foreign  material.  The  exposed  mucous  membrane  ex- 
foliates its  superficial  epithelium,  which  accumulates  within 
the  meatus,  or  adheres  to  the  walls  as  thin  yellowish-white 
or  brownish  scales.  These  masses  frequently  adhere  quite 
firmly  to  the  walls  of  the  meatus,  and  upon  separating  them 
a  denuded  area  remains.  The  presence  of  this  desquamated 
material,  together  with  the  moisture  normally  present  in  the 
canal,  favors  the  development  of  the  various  forms  of  asper- 
gillus,  causing  a  slight  discharge,  or  in  severe  cases  an  acute 
external  otitis,  with  the  attendant  symptoms  of  pain,  etc. 
The  hearing  is  usually  fairly  constant,  any  variation  from 
this  condition  being  coincident  with  congestive  changes  in 
the  upper  air  passages,  as  when  the  individual  suffers  from 
an  acute  coryza  or  from  an  acute  naso-pharyngitis. 

The  development  of  cholesteatoma  may  manifest  itself  in 
cases  which  have  remained  quiescent  for  a  long  period.  In 
certain  cases  the  superficial  epithelium  of  the  canal  migrates 
into  the  tvmpanic  cavity  and  replaces  the  pavement  epithelium 
of  the  mucous  membrane.  These  epidermal  cells  are  devel- 
oped with  unusual  rapidity  and  as  quickly  thrown  off.  As 
the  result,  the  tvmpanum  is  filled  with  a  mass  of  epithelial 
cells  which  steadily  increases  in  size  and  exerts  great  pressure 


426 


OTITIS    MEDIA    PURULENTA    RESIDUA. 


upon  the  surrounding  bony  walls.  The  mastoid  cells  at  a 
later  period  are  invaded.  The  partitions  between  the  pneu- 
matic spaces  are  broken  down,  converting  this  series  of  small 
cavities  into  one  large  cavity. 

Such  a  mass  may  produce  no  distinctive  symptoms  until 
the  tympanum  becomes  acutely  inflamed  from  some  cause, 
when  the  sudden  increase  in  volume  due  to  the  absorption 
of  the  products  of  the  inflammatory  process  induces  acute 
symptoms  referable  to  the  mastoid  or  middle  ear. 

Where  a  suppurative  inflammation  has  existed  for  a  long 
time  a  condensing  osteitis  of  the  mastoid  not  uncommonly 
occurs.  This  may  continue  after  suppuration  in  the  tym- 
panum has  ceased.  The  mastoid  then  becomes  the  seat  of  in- 
tense pain,  either  constant  or  paroxysmal,  while  neither  the 
mastoid  nor  middle  ear  presents  any  evidence  of  acute  inflam- 
mation. The  possibility  of  such  a  process  should  always  be 
borne  in  mind  when  persistent  neuralgia  of  the  mastoid  region 
is  met  with  in  a  subject  who  has  suffered  from  a  purulent 
otitis  at  any  previous  period. 

In  this  connection  it  might  be  mentioned  that  in  any  case 
of  persistent  facial  neuralgia  of  obscure  origin  the  ear  should 
always  be  examined.  1  have  found  in  cases  coming  under 
observation  for  some  aural  affection,  that  frequently  the  treat- 
ment of  the  ear  has  arrested  the  attack  of  facial  neuralgia,  and 
the  patients  have  of  their  own  accord  asseverated  the  facts. 

It  should  be  remembered  that  a  suppurative  inflammation 
in  early  infancy  may  leave  no  evidence  in  adult  life  except  a 
minute  pit  or  opening  above  the  short  process  of  the  malleus. 
In  these  cases  in  particular  the  remains  of  the  former  affec- 
tion may  produce  the  symptoms  in  question. 

Diagnosis. — A.  P)iysical  Exanmiation. — The  condition,  as 
revealed  by  an  examination  of  the  parts,  is  of  but  little  serv- 
ice in  estimating  the  degree  of  impairment  of  hearing,  or 
the  relation  between  this  impairment  and  the  trouble  present 
in  the  middle  ear.  It  is  only  by  a  thorough  functional  exami- 
nation in  connection  with  minute  ocular  inspection  that  we 
can  correctly  judge  as  to  how  much  of  the  interference  with 
function  depends  upon  the  changes  within  the  tympanum,  as 
distinguished  from  that  caused  by  the  labyrinthine  involve- 
ment. 

B.  Functional  Examination. — Where  the  middle  ear  alone 
is  affected,  the  examination  by  means  of  musical  tones  and 


FUNCTIONAL    EXAMINATION    AND    PROtiNOSIS.         427 

the  ordinary  tests  for  hearing  yields  results  characteristic  of 
obstruction  to  sound  conduction.  These  are  elevation  of  the 
lower  tone  limit,  very  slight  lowering  of  the  upper  tone  limit, 
or  no  deviation  from  the  normal  standard,  increased  bone 
conduction,  and,  if  one  side  alone  is  affected,  a  lateralization  to 
the  affected  side  of  the  vibrating  tuning  fork  held  upon  the 
forehead  in  the  median  line.  Moreover,  the  impairment  is 
usually  relatively  greater  for  the  voice  than  for  sharp  sounds, 
such  as  those  of  the  watch  or  acoumeter.  The  degree  of 
impairment  for  spoken  or  whispered  words  is  proportionate 
to  the  height,  in  the  musical  scale,  to  which  the  relative  dura- 
tion of  air  and  bone  conduction  is  reversed,  the  inversion 
extending  to  the  upper  notes  when  the  degree  of  impairment 
is  marked,  but  affecting  only  the  lower  portion  of  the  scale 
when  this  impairment  is  but  moderate. 

When  the  labyrinth  has  become  involved  we  have,  in  ad- 
dition to  the  evidences  of  interference  with  sound  conduction, 
certain  signs  characteristic  of  changes  in  the  lower  portion  of 
the  cochlea.  The  upper  tone  limit  is  almost  invariably  low- 
ered to  a  marked  extent,  usually  below  20,000  V.  S.  Where 
the  elevation  of  the  lower  tone  limit  remains  the  same  as  in 
uncomplicated  cases,  absolute  bone  conduction  is  usually 
diminished,  and  this  is  alwavs  the  case  when  serious  labyrin- 
thine involvement  is  present.  Occasionally  it  may  be  normal 
or  increased.  The  tuning  fork  held  upon  the  vertex  is  sel- 
dom lateralized  to  the  poorer  ear.  Tiie  imj)ortant  diagnostic 
test  is  an  observation  of  the  relation  between  the  impairment 
for  whispered  or  spoken  words  and  the  jujsition  in  the  musi- 
cal scale  at  which  the  reversal  between  air  and  bone  conduc- 
tion ceases.  It  will  be  found  that  where  impairment  is  due 
chiefly  to  labvrinthine  changes  the  impairment  of  hearing 
will  be  very  marked,  while  the  ratio  between  air  and  bone 
conduction  will  be  reversed  only  for  the  very  lowest  notes. 
In  such  instances,  even  if  the  abnormal  tension  in  the  sound- 
conducting  mechanism  can  be  corrected,  sufficient  changes 
have  taken  place  in  the  perceptive  apparatus  to  render  these 
measures  of  but  little  value  in  improving  the  hearing. 

Prognosis. — The  disease  under  discussion  is  usually  more 
amenable  to  treatment  than  any  other  form  of  chronic  tym- 
panic inflammation.  If  left  to  itself,  the  majority  of  cases 
either  do  not  progress  at  all,  or  deterioration  is  so  slow  as  to 
enable  us  to  promise  that  it  will  cause  but  little  increased  in- 


428  OTITIS    MEDIA    PURULENTA    RESIDUA. 

convenience  in  the  future.  A  certain  proportion  of  these 
cases  improve  spontaneously.  This  is  particularly  true  in 
children  or  young  adults,  the  continued  massage  of  the  parts 
by  the  sonorous  vibrations  to  which  they  are  subjected 
gradually  stretching  the  adhesions  or  causing  their  resorp- 
tion. After  the  age  of  thirty  or  thirty-five  this  probably  never 
takes  place  spontaneously.  After  proper  treatment  the  con- 
dition seldom  recurs,  and  any  improvement  is  likely  to  be 
permanent,  it  being  more  probable  that  the  condition  will 
even  improve  in  subsequent  years.  The  degree  of  improve- 
ment to  be  attained  depends  more  upon  the  degree  of  laby- 
rinthine involvement  than  upon  any  other  one  circumstance. 
If  this  is  considerable,  measures  directed  toward  the  middle 
ear  probably  aggravate  the  condition  rather  than  benefit  it. 
This  is  specially  true  of  surgical  measures.  Certain  cases 
come  under  observation  on  account  of  a  sudden  impairment 
of  audition,  and  examination  may  reveal  serious  interference 
with  the  labyrinth.  Where  these  changes  are  recent,  meas- 
ures directed  to  the  middle  ear  are  not  contraindicated,  since 
the  disturbance  within  the  labyrinth  may  depend  upon  some 
recent  change  in  the  sound-conducting  mechanism  which  has 
not  advanced  to  such  an  extent  as  to  render  the  removal  of 
the  cause  ineffectual  in  relieving  the  condition. 

Treatment. — Where  the  symptoms  depend  upon  swelling 
of  the  mucous  membrane,  measures  directed  toward  the  regu- 
lation of  the  habits  of  life  especially  are  among  the  first  indi- 
cations. Next,  the  condition  of  the  upper  air  passages  should 
be  thoroughly  investigated  and  any  obstructive  condition 
corrected.  This  is  particularly  true  where  functional  exami- 
nation indicates  labyrinthine  interference,  on  account  of  the 
intimate  relation  between  the  venous  return  current  from  the 
labyrinth  and  that  from  the  nasal  passages.  If  these  meas- 
ures are  not  successful,  topical  applications  to  the  lining 
membrane  of  the  middle  ear  are  to  be  instituted.  These 
should  be  of  mildly  astringent  character  at  first,  the  strength 
being  increased  if  necessary.  It  is  interesting  in  this  connec- 
tion to  remark  that  although  the  membrana  tympani  may  be 
almost  completely  destroyed,  a  restoration  of  the  lumen  of 
the  Eustachian  tube  to  its  normal  calibre  will  frequently  re- 
lieve the  symptoms.  This  depends,  no  doubt,  upon  the  re- 
moval of  obstruction  to  the  venous  return  current  from  the 
tympanum.    The  condition  within  the  Eustachian  tube  either 


TREATMENT.  429 

may  vicld  to  simple  inflation  or  mav  demand  the  use  of  some 
stimulating  vapors,  and  in  the  more  severe  cases  it  may  be 
necessary  to  resort  to  the  bougie. 

We  should  never  lose  sight  of  one  fact,  and  that  is  the  ex- 
treme susceptibilitv  of  these  cases  to  the  development  of  one 
of  the  vegetable  molds.  This  may  keep  up  a  chronic  conges- 
tion of  the  lining  membrane  of  the  middle  ear  in  spite  of  the 
treatment  already  mentioned,  and  we  should  always  be  cer- 
tain that  the  meatus  is  in  a  fairly  aseptic  condition  in  order 
that  this  factor  may  be  eliminated.  Where  hvpertrophic 
changes  are  more  extensive  and  small  aggregations  of  newly- 
formed  tissue  are  found  in  anv  localitv.  these  may  be  de- 
stroyed in  situ  either  by  the  potential  cautery  or  by  chemical 
agents,  but  they  are  seldom  large  enough  to  be  removed  bv 
means  of  the  curette  or  snare.  Occasionally  a  small  crust 
will  develops  in  the  upper  posterior  quadrant,  directly  over 
the  region  of  the  oval  or  round  windows,  preventing  the 
transmission  of  aerial  vibrations  to  the  labyrinthine  fluid. 
Such  an  obstruction  may  be  removed  by  the  forceps,  curette 
or  syringe,  as  seems  indicated  in  the  particular  case.  It 
should  be  remembered  that  the  removal  of  such  a  mass  may 
be  followed  by  a  recurrence  of  the  discharge,  and  it  is  wise 
to  mention  this  fact  to  the  patient  before  operating. 

Where  the  tense  margin  of  a  remnant  of  the  membrana 
tympani  displaces  the  ossicles  in  any  manner,  the  division 
of  the  fold  by  means  of  the  knife  is  frequently  followed  by  an 
astonishing  improvement  in  function.  The  section  can  be 
made  under  cocaine  anaesthesia,  and  if  proper  aseptic  precau- 
tions are  observed  in  preparing  the  field  of  operation,  the  pro- 
cedure is  followed  by  no  discomfort.  It  is  frequently  neces- 
sary to  repeat  the  section  several  times,  the  parts  reuniting 
after  division.  They  do  not,  however,  unite  throughout  the 
entire  length  of  the  incision,  and  by  repeating  the  procedure 
the  tension  is  gradually  relieved.  When  an  obstructing  band 
can  not  be  exactly  located  in  those  cases  where  the  entire 
ossicular  chain  remains,  and  other  measures  have  failed  to 
effect  the  desired  improvement,  it  is  wise  to  remove  the  re- 
mains of  the  membrana  tympani,  together  with  the  two 
larger  ossicles,  thus  exposing  the  round  window  and  the 
stapes,  the  latter  ossicle  being  dealt  with  according  to  the 
condition  found  upon  inspection.  This  plan  is  advocated 
after  considerable  practical  experience  in  cases  of  this  char- 


430 


OTITIS    MEDIA    PURULENTA    RESIDUA. 


acter ;  and  although  relief  is  sometimes  obtained  by  dividing- 
rather  blindly  various  constricting  bands  which  lie  beyond 
the  field  of  vision,  but  are  known  to  be  present  from  the  posi- 
tion which  the  ossicles  assume,  we  seldom  obtain  sufficient 
amelioration  to  be  satisfactory  either  to  the  surgeon  or  to  the 
patient,  and  at  length  resort  to  the  more  complete  opera- 
tion already  mentioned.  It  is  wise,  therefore,  to  make  this 
the  operation  of  election,  and  to  eliminate  thoroughh'  all 
interference  with  tension  in  the  conducting  chain  at  a  single 
operation. 

Where  the  stapes  is  exposed,  the  incudo-stapedial  articula- 
tion having  been  destroyed,  several  plans  of  treatment  are 
open  to  us.  The  simplest  is  auto-mobilization,  by  inserting 
an  artificial  drum  membrane,  such  as  a  small  disk  of  paper  or 
a  small  pledget  of  cotton.  This  is  applied  with  the  forceps 
or  cotton  holder,  so  as  to  rest  upon  the  head  of  the  stapes,  and, 
by  increasing  the  surface  presented  for  the  reception  of  aerial 
vibrations,  causes  them  to  exert  a  more  powerful  force  upon 
the  stapes.  Decided  improvement  has  followed  this  plan  in 
several  cases.  Where  manipulation  by  means  of  the  probe 
shows  that  the  stapes  is  firmly  fixed,  it  is  well  to  break  up 
these  adhesions  by  manipulation,  the  knife  being  employed  to 
divide  the  more  dense  bands  if  necessary.  The  technique  of 
these  operations  will  be  described  in  a  chapter  devoted  to 
the  operative  surgery  of  the  middle  ear. 

Concerning  the  advisability  of  the  extraction  of  the  stapes 
good  results  have  been  obtained  in  these  residuary  cases.  It 
is  a  question  in  my  mind,  however,  whether  we  can  not  obtain 
similar,  or  even  better,  results  by  leaving  the  stapes  in  place 
and  mobilizing  it  mechanically  ;  for,  although  I  have  removed 
it  a  number  of  times  with  good  results,  I  have,  in  cases  pre- 
senting similar  symptoms  and  responding  in  the  same  manner 
to  functional  tests,  seen  no  improvement  whatever  follow  the 
operation.  If  the  entire  stapes  can  be  removed,  it  can  cer- 
tainly be  mobilized,  and  the  foot  plate  probably  transmits  the 
sonorous  waves  to  the  labyrinth  more  perfectly  than  does  the 
cicatricial  membrane  which  is  formed  after  its  removal. 
Where  ossification  at  the  stapedio-vestibular  articulation  has 
taken  place,  the  removal  of  the  part  piecemeal  may  be  at- 
tempted. This  procedure  is  effected  either  by  means  of  a 
sharp  spoon  or  by  a  small  burr,  which  wears  away  the  thin, 
bony  lamella  separating  the   labvrinth   from   the  tvmpanum. 


TREATMENT.  43 1 

The  burr  should  be  conical  in  shape  and  so  guarded  as  to 
prevent  its  entering-  the  labyrinth  more  than  a  millimetre, 
when  the  foot  plate  is  perforated. 

Adhesions  about  the  round  window  can  seldom  be  seen, 
but  their  presence  may  be  suspected  when  the  niche  of  the 
fenestra  rotunda  is  surrounded  by  hypertrophied  mucous 
membrane.  Stellate  incision,  by  means  of  an  angular  knife 
inserted  into  the  niche,  will  relieve  tension  here,  and  is  fre- 
quently followed  by  improvement  in  connection  with  opera- 
tive procedures  about  the  oval  window.  Concerning  any 
aggravation  of  symptoms  which  surgical  measures  ma)'  in- 
duce, I  can  only  say  that  their  occurrence  is  vcrv  rare,  if  we 
bear  in  mind  the  rule  that  when  serious  labyrinthine  disturb- 
ance is  present  operative  measures  are  ct)ntraindicated. 

Where  the  labyrinth  is  involved  the  internal  administra- 
tion of  pilocarpine  often  relieves  the  tension  and  is  followed 
by  an  amelioration  of  the  svmptoms.  After  this  has  occurred, 
if  functional  examination  indicates  that  the  tvmpanic  lesion  is 
a  competent  cause  of  the  interference  with  function,  opera- 
tive measures  now  become  proper.  Where  the  residual  con- 
dition is  present  in  but  one  ear,  the  effect  upon  the  organ  of 
the  opposite  side  is  always  to  be  borne  in  mind.  If  the  oppo- 
site ear  becomes  affected,  the  changes  first  met  with  are  usu- 
ally labvrinthine  in  character,  and  operative  measures  may  be 
indicated  for  the  preservation  of  the  sound  organ,  although  the 
ear  operated  upon  may  be  beyond  relief.  It  is  sometimes 
stated  that  interference  in  these  residuary  cases  may  be  fol- 
lowed by  a  recurrence  of  the  discharge,  but  it  has  never  been 
my  experience  to  witness  this.  A  discharge  from  an  ear 
which  is  the  seat  of  a  residual  process  can  depend  only  upon 
the  presence  of  some  foreign  bodv  ;  and  no  operative  meas- 
ures, if  properly  carried  out.  would  lead  to  the  development 
of  this  condition — that  is,  to  the  development  of  bony  ne- 
crosis. 


IV.    DISEASES   OF   THE  MASTOID  PROCESS. 


CHAPTER   XXIV. 


THE  ANATOMY   OF   THE   MASTOID    PROCESS. 


In  considering  the  anatomy  of  the  ear  a  detailed  descrip- 
tion of  the  mastoid  process  was  not  given,  it  seeming  wiser 
to  incorporate  the  necessary  details  in  the  section  on  Diseases 
of  the  Mastoid.  The  mastoid  portion  of  the  temporal  bone 
is  an  irregular  conical  mass  of  osseous  tissue  located  behind 
the  external  auditory  meatus  and  projecting  for  a  varying 
distance  below  the  level  of  its  floor.  Its  lower  extremity, 
forming  the  apex  of  the  cone,  is  covered  by  the  aponeurosis 

of  the  sterno-mastoid 
muscle.  This  muscle 
is  attached  not  onlv  to 
the  tip  of  the  process, 
but  also  for  a  consider- 
able distance  along  its 
internal  aspect.  Above 
the  insertion  of  the 
muscle  upon  the  inter- 
nal surface  of  the  mas- 
toid is  a  deep  furrow, 
the  digastric  groove, 
which  lodges  the  oc- 
cipital artery  and  furnishes  attachment  for  the  posterior  head 
of  the  digastric  muscle.  This  bony  mass  may  be  pneumatic, 
diploic,  or  sclerotic  in  structure.  In  the  pneumatic  mastoid 
(Fig.  1 1 6)  there  are  numerous  air  spaces  throughout  the  entire 
mass  ;  these  are  irregularly  distributed,  in  some  cases  lying 
almost  immediately  below  the  cortex,  while  in  other  instances 
they  are  situated  at  considerable  depth  below  the  outer  sur- 
face of  the  bone  and  are  specially  numerous  upon  its  anterior 
aspect ;  this  anterior  wall  of  the  mastoid  forms  the  posterior 

(432) 


Fig.  116. — The  pneumatic  mastoid.  The  section 
shows  the  relative  position  of  the  tympanic  vault 
and  mastoid  antrum  to  each  other  and  to  the 
intracranial  surface.     (Author's  specimen.) 


VARIATIONS    IX    STRUCTURE. 


433 


-tP 


V 


J 

I- ii;.    117. —  Diploic  mastoid. 


wall  of  the  external  auditory  canal,  and  when  the  cells  are 
well  developed  in  this  rei^ion  the  earliest  evidences  of  their 
involvement  in  an  inflammatory  process  appears  here.  One 
pneumatic  space  is  constant,  and  that  is  the  antrum.  This  cav- 
ity is  irregularly  pyramidal  in  shape,  communicates  with  the 
tympanic  vault  by  a  narrow  passage,  and  varies  considerably 
in  size  in  different  individuals.  At  birth  the  antrum  is  the 
only  space  developed,  the  others  being  formed  subsequently. 
We  not  infrequently  find  a  second  cell  of  considerable  size 
located  at  the  verv  tip 
of  the  process  ;  the  out- 
er bony  wall  of  this 
space  is  often  verv  thin 
— a  fact  which  is  of  con- 
siderable clinical  im- 
portance. 

In  the  diploic  mas- 
toid the  antrum  alone 
is  present,  the  remain- 
ing po'-tion  consisting 
of  diploic  tissue,  similar  to  that  fouiul  in  the  other  cranial 
bones  (Fig.  117). 

Where  the  mastoid  is  sclerotic  the  entire  process  consists 
of  a  dense  eburnated  mass  of  osseous  tissue ;  its  structure  is 
uniform  throughout,  presenting  not  even  the  sliglitest  vestige 
of  a  pneumatic  space,  with  the  exception  of  the  antrum,  and 
even  this  mav  be  of  small  size. 

Various  combinations  of  these  three  fcjrms  may  be  met 
with  in  individual  cases  ;  thus  a  sclerotic  process  may  have 
progressed  to  a  certain  point  and  ceased  spontaneously,  in 
which  event  the  trabeculas  will  be  firmer  than  normal  and 
the  pneumatic  spaces  of  small  size;  or- but  one  or  two  air 
cells  may  exist,  the  remaining  portion  being  diploic  in  struc- 
ture. 

Owing  to  the  invariable  presence  of  the  mastoid  antrum, 
its  location  is  a  matter  of  importance.  It  is  best  located  by 
bearing  in  mind  its  relation  to  the  superior  and  posterior  walls 
of  the  external  auditory  meatus.  If  two  lines  be  drawn — one 
horizontal,  tangent  to  the  superior  wall  of  the  external  audi- 
tory canal,  the  second  vertical  and  tangent  to  its  posterior 
wall — the  point  of  their  intersection  will  be  the  apex  of  a  tri- 
angle the  base  of  which  will  be  formed  by  that  portion  of  the 
29 


434 


THE    ANATOMY    OF    THE    MASTOID    PROCESS. 


/f^;*V-"i 


Fig.  ii8. — Horizontal  section  through  a  pneu- 
matic njastoid.  s.  Groove  for  lateral  sinus  ; 
a.  Mastoid  antrum  ;  /,  Tympanic  cavity  ;  i,% 
Posterior  wall  of  external  canal  ;  7i>,  7c> ,  Path 
of  instrument  from  surface  of  mastoid  to 
antrum.     (I'olitzer.) 


curvilinear  outline  of  the  meatus  included  between  the  points 
of  tangency  of  these  lines.      This  triangle  lies  immediately 

over  the  antrum  and  an 
artificial  opening  within 
this  space  will  enter  the 
cavity. 

Another  cell  which 
is  fairly  constant  is  that 
large  pneumatic  space 
located  at  the  tip  of  the 
apophysis.  The  outer 
bony  wall  of  this  cavity 
on  the  digastric  surface 
of  the  mastoid  is  often 
no  thicker  than  parch- 
ment, and  where  the  mas- 
toid is  the  seat  of  an  in- 
flammatory process  at- 
tended by  the  formation 
of  pus,  the  involvement  of  this  large  space  may  be  first  evi- 
denced by  the  presence  of  diffuse  tumefaction  near  the  mastoid 
oriefin  of  the  sterno-mastoid  muscle,  either  on  the  external  sur- 
face  or  more  usually  in  the  digastric  fossa,  in  which  case  the 
tumefaction  lies  immediately  beneath  the  body  of  the  muscle. 

The  relation  which  the  mas- 
toid bears  to  the  intracranial 
contents  is  of  importance  in  the 
performance  of  surgical  opera- 
tions in  this  region.  The  to- 
pographical relations  between 
the  mastoid  and  the  tympanum 
and  cranial  fosstC  are  best  con- 
sidered together,  since  operative 
procedures  upon  the  mastoid 
process  are  usually  demanded 
because  of  some  abnormal  con- 
dition within  the  tympanum, 
and  this  cavity  is  always  entered 
at  the  time  of  operation.  The 
roof  of  the  tympanum  is  formed  by  the  petro-squamous  suture 
and  supports  the  temporo-sphenoidal  lobe  of  the  cerebrum. 
The  vault  of  the  tympanum  and  mastoid  antrum,  then,  are  in 


Fig.  1  ig. — a.  Mastoid  antrum ;  s. 
Groove  for  lateral  sinus  ;  g.  Pos- 
terior wall  of  external  canal  ;  7.',  r.''. 
Path  of  instrument  from  surface  of 
mastoid  to  antrum.     (Politzer.) 


RELATIONS  WTTH  THE  CRANIAL  CONTENTS. 


435 


relation  above  to  the  middle  cranial  fossa  ;  hence  any  product 
of  inflammation  passini^  through  the  roof  of  the  tympanum 
enters  this  portion  of  the  cranial  cavity,  after  which  its  con- 
veyance along  the  superior  surface  of  the  petrous  portion  of 
the  temporal  bone  to  the  region  of  the  medulla  is  exceedingly 
simple.  As  the  mastoid  antrum  is  but  an  extension  backward 
of  the  vault  of  the  tympanum,  its  intracranial  relations  are 
the  same  as  are  those  of  tiic  tympanic  vault.  The  mastoid 
cells  are  also  in  relation  with  the  meninges  of  the  posterior 
cerebral  and  the  cerebellar  fossa:.  In  cases  of  intracranial 
involvement  complicating  mastoid  inflammation,  the  pirocess 
is  usually  confined  to  meninges  covering  the  posterior  cere- 
bral lobe  or  the  cerebellum.  When  extension  takes  place 
through  the  roof  of  the  tympanum  the  contents  of  the  middle 
cranial  fossa  is  usually  involved. 

The  internal  surface  of  the  mastoid  process  presents  a  deep 
groove  for  the  lodgment  of  the  lateral  sinus.  The  distance 
which  this  vessel  may  extend  into  the  mastoid  varies  in  indi- 
vidual cases  ;  usuallv  it  lies  be- 
hind the  antrum,  and  in  some 
instances  the  bend  of  the  sinus 
is  so  sharp  that  the  acute  angle 
extends  forward  so  as  to  lie  but 
a  short  distance  behind  the  pos- 
terior wall  of  the  external  audi- 
tory meatus,  and  may  be  so  near 
the  surface  of  the  process  as  to 
cover  the  antrum  (see  Fig.  120). 
It  is  evident  that  with  the  sinus 
in  this  position  an  artiticial  open- 
ing into  the  antrum  could  not 
be  made  at  the  site  of  election 
for  entering  this  cavitv  without 
exposing  or  wounding  this  large 
venous  channel.  In  Fig.  118  the  parts  are  so  placed  that  the 
sinus  is  in  no  danger,  while  in  Fig.  119  it  could  be  avoided 
with  care. 

An  examination   of  numerous  specimens   has   been  made 
by  both  Korner  *  and  Randall  f  for  the  purpose  of  determin- 


FiG.  120. — /,  Tympanic  cavity;  «, 
Fidor  of  external  meatus  ;  s,  (Jioove 
for  lateral  sinus  ;  to,  w',  I'ath  of  in- 
strument from  surface  of  mastoid  to 
antrum.  In  this  case  the  sinus  wouid 
be  wounded  in  the  operation,  (j'o- 
litzer.) 


*  Arch,  of  Otol.,  vol.  xviii,  p.  310. 

f  Trans,  of  the  Amer.  Otol.  Society,  1892,  p.  235. 


436  THE    ANATOMY    OF    THE    MASTOID    PROCESS. 

ing  whether  the  location  of  the  sinus  could  be  positively  de- 
cided by  external  measurements  of  the  skull.  These  re- 
searches prove  conclusively  that  external  measurements  are 
useless  in  determining  the  site  of  the  sinus.  This  venous 
channel,  then,  bears  an  important  relation  to  the  mastoid  pro- 
cess, and  its  variable  situation  must  always  be  borne  in  mind 
in  operative  procedures.  When,  for  any  reason,  it  seems  de- 
sirable to  expose  the  sinus  during  an  operation,  it  can  be  done 
by  extending  the  opening  in  the  bone  backward,  care  being 
taken  to  avoid  the  removal  of  any  bone  beyond  the  occipito- 
temporal suture.  The  groove  lodging  the  knee  of  the  sinus 
is  located  in  the  mastoid  process,  and  an  extension  of  the  open- 
ing to  the  point  of  junction  between  the  occipital  and  temporal 
bones  affords  abundant  space  for  examination  of  the  sinus  as 
well  as  of  the  condition  of  the  posterior  cranial  fossa  both 
above  and  below  the  tentorium.  This  statement  regarding 
the  extensive  removal  of  bone  in  exposing  the  sinus  may 
seem  unnecessary,  but  where  the  j)atient  is  anaemic  the  ex- 
posed sinus  may  be  nearly  empty  and  its  walls  may  be  of  the 
same  color  as  the  contiguous  meningeal  surface,  rendering  its 
recognition  difficult. 

From  the  presence  of  this  vessel  it  is  advisable  in  all  oper- 
ations upon  the  mastoid  first  to  remove  the  cortex  as  close  to 
the  posterior  wall  of  the  canal  as  possible.  After  the  cells 
are  entered  and  the  topography  of  the  particular  process  is 
ascertained,  the  opening  may  then  be  enlarged  as  much  as  is 
necessary,  but  the  cavitv  should  ahvavs  be  entered  as  close 
to  this  line  as  possible. 

In  the  majority  of  cases  the  middle  cranial  fossa  lies  at  a 
considerably  higher  level  than  the  horizontal  plane  passing 
through  the  superior  wall  of  the  bony  meatus.  The  location 
of  the  floor  of  this  space  is  commonly  above  the  plane  pass- 
ing through  the  temporal  ridge,  this  last  term  being  applied 
to  the  prolongation  of  the  roof  of  the  zvgoma  backward 
over  the  entrance  of  the  external  auditory  canal.  The  tem- 
poral ridge  was  for  a  time  considered  the  upper  limit  of 
safety  in  opening  the  mastoid  process.  Occasionally,  how- 
ever, we  meet  with  cases  in  which  the  squamous  portion  of 
the  temporal  bone,  instead  of  lying  almost  vertical,  is  consid- 
erably inclined,  forming  an  acute  angle  with  the  horizontal 
plane.  When  this  occurs  the  temporal  ridge  overhangs  the 
entrance  to  the  meatus  (Fig.  121).     Unless  care  is  exercised. 


UKVKLOI'MKNTAL    CHANGES. 


437 


the  superior  margin  of  the  canal  will  not  be  correctly  located, 
the  prominent  ridcre  being  mistaken  for  it.  It  will  easily  be 
seen  that  if  the  chisel  is  now  applied  over  what  seems  to  be 
the  area  ordinarily 
selected  for  perfo- 
rating the  cortex,  the 
opening  will  be  situ- 
ated above  the  mas- 
toid antrum,  and  the 
middle  cranial  fossa 
will  be  entered.  Care 
should  be  taken, 
therefore,  to  recog- 
nize this  anomaly, 
and  to  be  certain 
that  the  superior 
margin  of  the  canal 
is  really  exposed  be- 
fore the  bone  is  per- 
forated. In  young 
children  this  promi- 
nence of  the  tem- 
poral ridge  is  a  usual 
condition,  owing    to 

the  exceedingly  oblique  angle  between  the  squama  and  the 
auditory  plate  (Figs.  6  and  122). 

In  the  infant  at  birth  the  mastoid  is  but  poorly  developed, 
consisting  usually  of  but  a  single  cell — the  antrum.  It  must 
be  remembered,  however,  that  there  is  a  very  large  pneumatic 
space  in  immediate  relation  to  the  tympanic  cavity,  as  the 
vault  of  the  tympanum  in  the  child  is  nearly  as  large  as  in 
the  adult,  the  ossicles  increasing  but  little  in  size  from  the 
period  of  birth  to  adult  life.  This,  no  doubt,  explains  the 
cause  of  the  pronounced  symptoms  found  in  even  the  simpler 
inflammations  of  the  middle  ear  in  infancy  and  early  child- 
hood. The  inner  table  of  the  cranium  is  excessively  thin, 
and  frequently  incomplete  in  places  akjng  some  of  the  sutural 
lines.  The  vascular  supply  of  the  lining  membrane  of  this 
pneumatic  space,  made  up  of  the  vault  of  the  tympanum 
and  of  the  mastoid  antrum,  is  very  free  and  in  close  anasto- 
motic relation  with  the  intracranial  venous  sinuses.  For  this 
reason  symptoms  of  meningeal  irritation  are  frequently  ob- 


I"it"..  121. — Adult  leni|)oral  bone  in  wliicli  the  icm- 
pi>ral  ridge  overliangs  the  entrance  to  the  canal. 
(Author's  specimen.) 


438 


THE    ANATOMY    OF    THE    MASTOID    PROCESS. 


served,  even  in  a  mild  attack  of  otitis  media  in  infancy. 
Again,  a  fatal  termination  is  probably  more  common  than  we 
are  aware,  due  to  an  early  thrombosis  of  the  venous  sinuses, 
or  to  septic  meningitis.  These  may  occur  even  before  dis- 
charge appears  in  the  external  auditory  meatus,  and  perhaps 
without  special  attention  having  been  called  to  the  ear,  unless 
the  physician  is  aware  of  the  fact  that  one  of  the  most  fre- 
quent causes  of  high  temperature  in  young  infants  is  a  middle- 
ear  inflammation.  A  reference  to  Fig.  122,  which  is  a  draw- 
ing of  a  specimen  in  the  posses- 
sion of  the  author,  shows  how 
capacious  this  pneumatic  space 
may  be  at  birth. 

The  depth  at  which  the  mas- 
toid antrum  lies  varies  in  differ- 
ent cases.  It  is  seldom  entered 
at  a  depth  of  less  than  half  an 
inch,  and  may  lie  seven  eighths 
of  an  inch  below  the  external 
surface.  The  only  structure  of 
importance  lying  within  the  mas- 
toid process  itself  is  the  facial 
nerve,  which  passes  out  through 
the  stvlomastoid  foramen.  The 
nerve  crosses  the  upper  portion 
of  the  tympanic  cavity  in  the 
aquneductus  Fallopii.  and  leaves 
the  cavitv  through  an  opening 
in  the  posterior  wall.  In  the  mastoid  its  course  is  downward, 
outward,  and  slightly  backward,  crossing  the  line  of  the  pos- 
terior canal  wall  at  the  junction  of  the  lower  and  middle 
third.  Since  it  is  deeply  placed  and  the  bony  wall  covering 
it  is  so  dense,  it  is  seldom  wounded,  and  a  little  care  will 
enable  the  operator  to  avoid  it.  Immediatelv  above  the 
aquaeductus  Fallopii  we  find  the  horizontal  semicircular  canal. 
This  structure  can  be  injured  only  by  continuing  the  artificial 
opening  beyond  the  level  of  the  internal  wall  of  the  tym- 
panum, an  accident  which  need  not  occur  if  ordinary  care  is 
exercised.  The  same  mav  be  said  of  wounding  the  facial 
nerve  in  its  passage  through  the  aqueduct. 


Fig.  122. —  Ihe  tympanic  vault  and 
mastoid  antrum  at  birth,  a,  Ex- 
ternal canal  separated  from  sur- 
face of  squama.  At  its  inner 
extremity  is  the  membrana  tym- 
pani  inclosed  by  the  tympanic 
ring.  Above  the  ring  the  mal- 
leus and  incus  are  plainly  seen. 
(Author's  specimen,  natural  size.) 


CHArri-.R  xx\'. 

INFLAMMATION    OF    HIF    MA^loII)    rRocESS. 

iEtiology. — The  most  common  cause  of  an  acute  inflam- 
mation in  tliis  region  is  an  extensicMi  of  a  similar  process  from 
the  middle  ear.  The  primary  lesion  mav  be  cither  acute  or 
chrc^nic  in  character,  although  it  is  jirobahle  that  a  sinijile 
catarrhal  inflammation  does  not  involve  the  mastoid  process 
bv  extension.  In  cases  where  the  mastoid  is  involved,  during 
the  course  of  what  has  seemed  to  be  a  catarrhal  inflammation, 
it  is  believed  that  the  [)rocess  within  the  middle  ear  has  al- 
ready changetl  in  character  and  that  the  involvement  of  the 
mastoid  has  occurred  at  a  verv  earlv  stage  on  account  of  the 
intensity  of  the  process,  which  has  attacketl  not  only  the  mid- 
dle ear,  but  the  communicating  j)neumatic  chamber  as  well. 

Primary  mastoiditis,  although  uncommon,  is  occasionally 
seen,  and  mav  follow  an  exposure  tt)  cold  or  a  traumatism,  or 
may  be  a  manifestation  of  a  tubercular  or  specific  diathesis. 
This  last  condition  is  probably  the  most  common  cause  of  a 
primary  mastoid  inflammation,  a  gummatous  deposit  occur- 
ring and  subsequently  breaking  down  in  the  characteristic 
manner.  Inflammatory  conditions  within  the  meatus  may  also 
extend  to  the  mastoid  by  contiguity.  A  sim[)le  circumscribed 
inflammation  may  produce  this  result,  especially  when  located 
upon  the  posterior  wall  of  the  canal.  Diffuse  external  otitis 
may  cause  a  similar  condition.  Chronic  suppurative  inflam- 
mation  of  the  middle  ear  is  the  most  common  cause  of  an 
acute  mastoiditis.  It  seems  curious  that,  from  the  intimate 
relation  which  exists  between  the  mastoid  cells  and  the  tym- 
panum, the  latter  cavity  may  be  the  seat  of  a  jnirulent  in- 
flammation for  years  without  producing  a  similar  condition 
within  the  mastoid.  From  some  slight  cause,  frequently  so 
trivial  in  character  as  to  be  unrecognized,  infection  in  this 
region  occurs,  terminating  in  extensive  destruction  of  the 
osseous  tissue. 

(439) 


440 


INFLAMMATION    OF    THE    MASTOID    PROCESS. 


Pathology. — A  chronic  purulent  otitis  media  causes  cer- 
tain changes  within  the  mastoid,  attended  bv  a  thickening  of 
the  membrane  lining  the  cells  and  an  increase  in  the  vascu- 
larity. These  changes,  continuing,  lead  to  a  deposit  of  new 
osseous  tissue,  which,  in  the  most  marked  cases,  converts  the 
entire  process  into  a  mass  of  compact  bone  of  ivorylike  con- 
sistence and  obliterates  the  cells  comj)letelv. 

Again,  instead  of  a  hypertrophic  change,  a  local  necrosis 
may  result.  If  this  affects  a  large  area,  a  sequestrum  is  formed, 
which  is  either  exfoliated  spontaneously  or  demands  operative 
measures  for  its  removal.  If  the  destruction  takes  place  over 
but  a  limited  area,  the  disintegrated  tissue  is  discharged  as 
pus  ;  when  moderate  in  amount  and  a  free  exit  is  afforded 
through  the  external  auditory  canal,  the  copious  discharge 
from  the  canal  may  be  the  sole  evidence  of  the  involvement 
of  the  mastoid  cells.  If,  however,  drainage  is  not  free,  symp- 
toms  of  pus  retention  are  manifested. 

The  presence  of  infectious  material  within  the  bon)-  cavity 
may  produce  several  results  ;  the  simplest,  already  mentioned, 
is  a  copious  otorrhcea.  If  drainage  through  the  canal  is  im- 
peded, the  fluid  must  find  exit,  and  evacuates  itself  spontane- 
ously where  the  least  resistance  is  offered.     This  may  be — 

1.  Through  the  external  mastoid  cortex,  either  behind  the 
ear  or  in  the  external  meatus. 

2.  Through  the  cortex  in  the  digastric  fossa. 

3.  Through  the  roof  of  the  antrum,  or  of  the  tympanic 
vault,  into  the  middle  cranial  fossa. 

4.  Into  the  posterior  cranial  fossa,  usually  bv  ruj)ture  into 
the  groove  lodging  the  lateral  sinus. 

When  the  cranial  cavity  is  invaded  we  have  an  inflamma- 
tion of  the  meninges,  which  may  be  diffuse  or  circumscribed. 
In  the  former  condition  a  purulent  leptomeningitis  results, 
while  in  the  latter  an  epidural  abscess  is  formed.  The  pro- 
duction of  an  epidural  abscess  seems  to  be  an  effort  on  the 
part  of  Nature  to  limit  the  inflammation  to  a  circumscribed 
area,  the  infectious  material  being  walled  in  on  all  sides  by 
adhesions  between  the  dura  and  the  adjacent  osseous  walls. 
Internal  rupture  is  not  the  only  manner  in  which  the  contents 
of  the  cranial  cavity  may  be  invaded  ;  the  free  anastomosis 
between  the  blood  vessels  of  the  dura  and  the  pericranium 
may  furnish  the  avenue  through  which  the  infectious  material 
may   pass  to  the  intracranial  contents.     In   this  manner  we 


INTRACRANIAL    COMPLICATIONS. 


441 


may  have,  in  addition  to  the  two  conditions  already  men- 
tioned, a  thrombosis  of  the  lateral  sinus,  or  an  abscess  within 
the  brain  substance.  Unfortunately  for  the  patient,  these 
lesions,  instead  of  being  single,  frequently  occur  together ; 
thus  a  sinus  thrombosis  without  considerable  meningitis  is 
rare,  while  a  brain  abscess  is  a  not  infrequent  accompaniment 
of  thrombosis  of  the  sinus. 

Where  rupture  takes  place  upon  the  external  surface  of 
the  mastoid,  it  is  commonly  supposed  that  all  serious  danger 
of  involvement  of  the  intracranial  contents  is  at  an  end,  al- 
though the  abscess  may  not  be  immediately  evacuated  by  in- 
cision of  the  overlying  soft  parts.  This  is  an  error,  particu- 
larly in  the  case  of  children.  Here  the  sutural  lines  between 
the  various  portions  of  the  temporal  bone  arc  not  completely 
ossified,  and  when  the  external  surface  of  the  temporal  bone 
is  bathed  in  pus,  infection,  either  through  the  sutural  lines  or 
through  the  substance  of  the  squama  itself,  is  by  no  means 
impossible. 

I  have  reported  one  case  of  this  character  in  a  child  and 
one  in  an  adult,*  while  several  other  instances  may  be  found 
in  otological  literature.  In  children  the  presence  of  pus  be- 
neath the  integument  in  the  post-aural  region  does  not  of  ne- 
cessity indicate  a  perforation  through  the  cortex.  In  these 
young  subjects  a  collection  of  fluid  within  the  tympanic  vault 
frequently  makes  its  way  along  the  superior  wall  of  the  canal, 
gaining  exit  from  the  cavity  through  the  Rivinian  segment 
by  dissecting  the  soft  parts  away  from  the  bone  in  this  loca- 
tion. In  very  young  infants  this  is  by  no  means  uncommon, 
while  in  children  over  ten  years  of  age  it  is  occasionally  met 
with.  Perforation  of  the  cortex  on  the  anterior  surface — that 
is,  through  the  posterior  wall  of  the  bony  meatus — may  occa- 
sionally occur.  Spontaneous  evacuation  here  is  probably  due 
to  the  fact  that  in  the  particular  case  the  external  cortex  is 
thicker,  while  along  the  posterior  aspect  of  the  canal  the 
pneumatic  cavities  are  well  developed  and  thin-walled.  Where 
sequestra  are  formed  the  process  does  not  differ,  except  that 
in  addition  to  the  fluid  collection  we  have  a  foreign  body 
whose  action  is  to  aggravate  the  changes  already  described. 
The  same  remark  applies  to  the  development  of  a  cholestea- 
tomatous  mass  within  the  mastoid  cells.     These  epithelial  col- 

*  Archives  of  Otology,  vol.  xxi,  p.  253. 
30 


442  INFLAMMATION    OF    THE    MASTOID    PROCESS. 

lections  are  rather  prone  to  excite  a  hyperplastic  inflamma- 
tion, terminating  in  sclerosis  with  obliteration  of  the  trabeculae 
between  the  cells.  It  is  only  when  the  mass  attains  consider- 
able size  that  acute  inflammatory  changes  are  set  up,  produc- 
ing a  train  of  symptoms  characteristic  of  an  acute  process  in 
this  region. 

The  cholesteatomatous  deposit  may  attain  such  a  size  as  to 
cause  absorption  of  the  posterior  wall  of  the  canal,  converting 
the  mastoid,  antrum,  tympanum,  and  bony  meatus  into  a  single 
cavity.  At  the  same  time  the  cortex  of  the  mastoid  is  often 
sclerosed. 

Symptomatology. — The  prominent  svmptom  met  with  is 
intense  pain  over  the  mastoid  portion  of  the  temporal  bone. 
The  pain  is  particularly  severe  at  night,  preventing  sleep.  It 
is  of  dull  character,  deep-seated  and  constant.  Following  a 
painful  inflammation  within  the  tympanum,  a  change  in  the 
character  and  location  of  the  pain  complained  of  by  the  pa- 
tient is  a  valuable  symptom.  The  degree  of  constitutional 
disturbance  presented  is  often  entirely  out  of  proportion  to 
the  local  changes.  The  patient  may  be  well  nourished,  the 
temperature  normal,  and  the  pulse  but  slightly  accelerated, 
while  at  the  same  time  extensive  destruction  is  taking  place. 
Where  the  disease  complicates  an  acute  process  within  the 
middle  ear,  or  is  primary  in  character,  the  temperature  is 
usually  elevated,  varying  from  995°  to  101.5°,  but  seldom 
higher  than  this.  An  extension  of  the  pain  to  the  temporal 
region  is  rarely  complained  of,  its  location  being  limited  to  the 
mastoid  process.  Where  the  cells  are  well  developed  at  the 
apex,  considerable  difificulty  may  be  experienced  in  moving  the 
head  from  side  to  side.  In  children  this  symptom  should  al- 
ways be  carefully  investigated,  although  no  pain  may  be  com- 
plained of  in  the  region  of  the  ear.  Tenderness  upon  deep 
pressure  is  probably  the  most  characteristic  sign  of  the  in- 
volvement of  the  osseous  structures.  This  varies  considerably 
in  location.  It  is  usually  most  marked  directly  over  the  an- 
trum and  close  to  the  posterior  margin  of  the  canal.  Occa- 
sionally the  most  tender  point  will  be  found  at  the  tip  of  the 
apophysis.  Where  a  previous  aural  discharge  has  been  pres- 
ent, the  access  of  the  symptoms  referable  to  the  mastoid  is 
frequently  accompanied  by  a  cessation  of  discharge  from  the 
canal  or  by  a  diminution  in  the  amount.  In  young  children 
who  are  unable  to  locate  exactly  the  seat  of  pain,  restlessness 


SYMPTOMATOLOGY— INTRACRANIAL    INVOLVEMENT.    443 

at  night  should  always  excite  suspicion  if  it  follows  the  cessa- 
tion of  a  profuse  aural  discharge.  Tumefaction  behind  the 
auricle  is  not  common,  except  in  early  life.  CEdcma  of  the 
overlying  soft  parts  is  more  characteristic  of  an  inflammation 
within  the  canal  than  of  involvement  of  the  mastoid  process. 
Fluctuation,  it  need  hardly  be  said,  indicates  spontaneous 
evacuation  of  the  purulent  contents. 

If  the  intracranial  structures  are  involved,  the  svmptoms 
manifested  depend  upon  the  particular  region  attacked.  If 
one  of  the  large  venous  sinuses  becomes  the  seat  of  an  infec- 
tious thrombus,  the  temperature  changes  are  the  most  charac- 
teristic evidence  of  the  condition.  They  consist  in  the -sud- 
den elevation  of  the  temperature,  the  thermometer  frequently 
registering  104°  or  105°.  This  elevation  persists  but  for  a  few 
hours,  and  is  followed  bv  a  spontaneous  fall  to  the  normal 
standard  or  even  lower  than  this.  These  intermittent  eleva- 
tions may  occur  several  times  during  the  dav,  and  may  be  of 
such  short  duration  as  to  be  unrecognized  unless  the  tempera- 
ture is  taken  frequentlv.  Following  the  access  of  the  fever 
there  is  profuse  perspiration,  and  as  the  condition  advances, 
well-marked  symptoms  of  general  sepsis  appear.  The  patient 
becomes  very  weak.  The  skin  is  of  a  dull,  ashv  hue,  the 
pulse  feeble,  and  the  mental  condition  dull,  all  ol  which  are 
indicative  of  profound  systemic  infection.  If  emboli  are  de- 
veloped, their  lodgment  in  the  various  viscera  is  followed  by 
characteristic  symptoms.  The  most  common  site  of  lodgment 
is  probably  the  lungs,  causing  a  septic  pneumonia.  When  the 
thrombus  develops  in  the  lateral  sinus  it  frequently  extends 
downward  into  the  internal  jugular  vein,  and  its  presence  is 
revealed  by  deep  tenderness  along  the  course  of  this  vessel, 
togrether  with  tumefaction  along  the  anterior  border  of  the 
sterno-mastoid  muscle.  Whenever  temperature  changes  ex- 
cite suspicion  of  involvement  of  the  sinus,  the  region  of  the 
external  jugular  vein  should  be  examined  frequently  for  con- 
firmatory signs.  The  sensorium  is  seldom  disturbed,  except 
just  before  death,  where  thrombosis  alone  is  present. 

Where  involvement  of  the  intracranial  structures  results 
in  diiTuse  meningitis,  we  have  intense  headache,  photophobia, 
a  liigh  temperature  which  remains  constant,  nausea,  and 
vomiting.  Otitic  meningitis  usually  involves  the  base  of  the 
brain  rather  than  the  convexity.  Hence  a  slow  pulse  charac- 
teristic of  traumatic  meningeal  inflammation  is  wanting,  the 


444  INFLAMMATION   OF   THE   MASTOID    PROCESS. 

cardiac  action  being  increased  in  rapidity.  Paralysis  of  in- 
dividual muscles  soon  appears,  the  third  and  sixth  nerves 
being  most  frequently  involved,  causing  either  strabismus  or 
paralysis  of  the  ciliary  muscle.  Rigidity  of  the  muscles  of 
the  neck  occurs  quite  early,  and  is  one  of  the  most  character- 
istic symptoms. 

Where  the  meningitis  is  localized,  constituting  an  extra- 
dural abscess,  the  temperature  is  usually  but  moderately 
elevated,  seldom  exceeding  ioo°.  The  characteristic  sym- 
tom  is  localized  headache,  the  painful  region  corresponding 
pretty  closely  to  the  area  involved.  Paralytic  symptoms  do 
not  appear  until  late  in  the  course  of  the  disease.  Rigidity 
of  the  muscles  of  the  neck,  vomiting  and  photophobia  are 
also  absent. 

The  occurrence  of  an  abscess  within  the  cerebral  sub- 
stance is  a  rare  accompaniment  of  acute  mastoid  inflammation. 
It  may  be  said  it  produces  no  symptoms  which  may  be  called 
characteristic  until  it  has  attained  sufficient  size  to  press  upon 
some  portion  of  the  motor  tract.  Its  presence  should  always 
be  suspected  when  there  is  a  persistent  low  temperature,  to- 
gether with  constant  headache,  increasing  asthenia,  and  pro- 
gressive hebetude.  So  far  from  producing  characteristic 
symptoms,  it  is  rather  the  absence  of  any  characteristic  mani- 
festation, but  the  failure  of  the  patient  to  improve,  which 
should  always  excite  suspicion  of  this  condition.  When  in 
an  acute  mastoiditis  the  pain  diminishes  in  severity  and  as- 
sumes the  character  of  a  general  headache,  while  at  the  same 
time  the  patient  becomes  progressively  dull  and  unobservant 
of  his  surroundings,  the  temperature  remaining  normal  or  but 
slightl}^  elevated,  invasion  of  the  cerebral  substance  should 
be  suspected.  The  occurrence  of  two  or  more  of  these  intra- 
cranial conditions  in  association  is  what  renders  a  diagnosis 
difficult.  A  brain  abscess  is  hot  an  uncommon  complication 
of  a  thrombosis  of  one  of  the  large  venous  channels.  The 
thrombus  causes  the  characteristic  intermittent  temperature 
and  masks  the  purulent  collection  situated  deeply  within  the 
cerebral  tissue.  It  is  also  common  to  find  considerable  menin- 
gitis with  either  cerebral  abscess  or  thrombosis  of  the  lateral 
sinus.  This  local  inflammation  prevents  the  temperature  from 
intermitting,  as  we  should  expect  it  to  do  if  the  sinus  alone 
were  involved,  and  the  fever  due  to  meningitis  may  render 
the  fluctuations  due  to  the  entrance  of  infectious  material 


DIAGNOSIS.  4^5 

into  the  circulation  at  frequent  intervals  entirely  unrecog- 
nizable. 

Diagnosis. — It  would  seem  that  the  recognition  of  the 
invasion  of  the  osseous  structures  immediately  surrounding 
the  tympanum  would  be  a  matter  of  simplicit)-,  and  quite 
frequently  no  diflficulty  is  experienced  in  making  a  diagnosis. 
On  the  other  hand,  we  meet  with  cases  in  which  even  the 
most  expert  observer  must  be  in  doubt  as  to  whether  the 
pneumatic  cells  of  the  mastoid  have  become  infected,  or 
whether  the  severe  constitutional  svmptoms  are  due  simplv 
to  the  conditions  witliin  the  tvmpanimi.  There  are  two  signs 
upon  which  the  most  dependence  can  be  placed,  and  the  jires- 
ence  of  both  is  a  certain  indication  of  mastoid  involvement, 
while  the  presence  of  either  one  alone  is  certainlv  suspicious 
and  often  constitutes  the  sole  sign  upon  which  the  necessity 
of  operative  treatment  is  based. 

These  two  signs  are  : 

1.  Local  tenderness  upon  deep  pressure  over  the  mastoid 
region. 

2.  A  depression  or  sagging  of  the  supero-posterior  wall 
of  the  canal  close  to  the  tvmpanic  ring. 

In  determining  mastoid  tenderness  care  must  be  taken  to 
be  sure  that  the  pain  experienced  by  the  patient  upon  ma- 
nipulation is  reallv  mastoid  tenderness,  and  does  not  depend 
upon  an  inflammation  of  the  external  canal.  No  error  need 
occur  if,  when  the  examination  is  made,  the  examining  finger 
is  pressed  backward  and  inward  upon  the  mastoid  just  be- 
hind the  insertion  of  the  auricle,  since  this  manipulation  does 
not  move  the  fibro-cartilaginous  canal.  On  the  other  hand, 
if  the  finger  of  the  operator  causes  even  the  slightest  move- 
ment of  the  auricle  or  of  the  meatus,  the  presence  of  an  exter- 
nal otitis  may  lead  to  error. 

The  tender  point  is  usuallv  situated  over  the  antrum,  and 
may  be  close  to  the  margin  of  the  bony  meatus  ;  even  here  it 
is  not  necessary  to  cause  the  slightest  motion  of  the  soft  parts 
if  the  thumb  be  placed  upon  the  margin  of  the  bony  ring 
and  pressure  exerted  backward  and  inward.  The  tenderness 
elicited  is  unmistakable,  the  patient  not  infrequentlv  cringing 
at  the  moment  when  the  parts  are  pressed  upon.  It  is  always 
wise  to  test  the  health v  mastoid  in  the  same  manner,  since  a 
certain  number  of  individuals  possess  what  may  be  called  a 
physiological  tenderness   of   the    mastoid    process.      This  is 


446  INFLAMMATION    OF   THE    MASTOID    PROCESS. 

probably  due  to  a  free  distribution  of  the  sensory  nerves  in 
this  location,  and  is  a  rather  characteristic  symptom  in  nerv- 
ous and  hysterical  individuals.  Occasionally  the  region  of 
the  antrum  ma}-  not  be  tender,  but  pain  is  elicited  when 
the  tip  of  the  mastoid  is  subjected  to  pressure.  Here  we 
must  be  cautious  not  to  be  misled  by  a  tenderness  over  the 
Eustachian  tube.  This  is  elicited  if  the  thumb  is  pressed 
upon  the  soft  parts  directly  behind  the  ramus  oi  the  jaw.  and 
is  almost  always  found  in  cases  of  severe  tympanic  inflamma- 
tion. To  avoid  this  error  it  is  only  necessary  to  direct  the 
pressure  backward  upon  the  tip  of  the  mastoid  process,  avoid- 
ing the  soft  parts  immediately  in  front.  Directly  over  the  in- 
sertion of  the  sterno-mastoid  muscle  tenderness  can  almost 
always  be  elicited  in  healthy  individuals  even  under  normal 
conditions,  and  it  is  consequently  of  but  little  moment  as  a 
diagnostic  sign. 

A  localized  tumefaction  of  the  postero-superior  canal  wall 
is  even  more  indicative  of  involvement  of  the  mastoid  than  is 
tenderness  behind  the  auricle.  The  examination  of  a  large 
number  of  specimens  will  show  that  the  pneumatic  spaces  are 
usually  as  richly  distributed  along  the  anterior  face  of  the 
process — which  constitutes  the  posterior  wall  of  the  canal — as 
beneath  the  external  surface  behind  the  auricle.  The  passage 
of  communication  between  the  vault  of  the  tympanum  and  the 
mastoid  antrum  also  lies  immediately  above  and  behind  the 
inner  extremity  of  the  bony  meatus,  the  postero-superior  canal 
wall  at  this  point  forming  the  floor  of  the  passage.  This  ex- 
plains why  the  sign  is  so  important  in  establishing  a  diagnosis. 
In  this  condition  we  hnd  the  fundus  of  the  canal  much  reduced 
in  size,  only  a  limited  portion  of  the  membrana  tvmpani  being 
visible,  although  the  lumen  of  the  meatus  is  normal  in  other 
situations.  A  primary  external  otitis  is  seldom  met  with  in 
this  locality,  and  I  have  never  met  with  an  instance  in  which, 
when  this  sign  was  present,  operation  upon  the  mastoid  did 
not  reveal  the  presence  of  pus.  The  tumor  within  the  canal 
is  extremely  sensitive  to  pressure  upon  manipulation  with  the 
probe,  and  is  dull  and  boggy  to  the  touch.  The  presence  of 
a  large  perforation  in  the  membrana,  through  which  secre- 
tion can  be  forced  by  auto-inflation,  does  not  necessarily  prove 
that  the  drainage  of  the  mastoid  process  is  competent.  It 
will  be  remembered  that  the  upper  portion  of  the  tympanic 
cavity  is  often  completely  shut  off  from  the  atrium  under  nor- 


DIAGNOSIS:   SITE    OF   TUMOR.  ^^-r 

mal  conditions,  and  when  the  parts  adjacent  are  oedematous 
from  inflammation  complete  obstruction  is  frequent. 

In  addition  to  these  two  signs  there  is  usually  severe  pain, 
especially  at  nig-ht ;  or,  if  not  pain,  sleeplessness  ;  the  last 
symptom  is  especially  noticeable  in  chronic  cases.  To  these 
patients  the  mastoid  pain  or  headache  has  become  a  second 
nature,  and  a  slight  increase  does  not  produce  the  same  effect 
as  the  corresponding  condition  in  a  {previously  health v  individ- 
ual, but  leads  to  loss  of  sleep.  Body  temj)erature  has  practical- 
ly no  diagnostic  value  ;  in  acute  cases  we  usually  find  an  ele- 
vated tem|)erature  varying  from  ioo°  to  102°  or  103°.  Where 
the  middle  ear  has  been  the  seat  of  a  suppurative  process  for 
a  long  period,  the  mastoid  subsequently  becoming  involved, 
it  is  not  infrequent  to  find  the  temperature  perfectly  normal, 
although  the  temperature  is  taken  so  frequently  as  to  pre- 
clude the  possibility  of  any  rise  being  overlooked.  Local 
redcma  behind  the  ear  is  more  characteristic  of  a  circum- 
scribed inflammation  of  the  canal  than  of  mastoid  involve- 
ment. In  young  children,  where  the  bony  meatus  is  not  de- 
veloped, tumefaction  behind  the  ear  is  frequently  found,  and 
evacuation  of  the  abscess  may  occur,  although  no  perforation 
through  the  cortex  is  present.  The  fluid  within  the  mastoid 
burrows  along  the  posterosuperior  canal  wall,  and  appears 
close  behind  the  auricle  quite  earlv,  owing  to  the  ease  with 
which  it  finds  an  exit  through  the  Rivinian  segment.  In 
children,  also,  the  cortex  of  the  mastoid  is  exceedingly  thin, 
and  perforation  may  take  ])lace  in  twenty-four  hours  after 
the  onset  of  an  acute  attack  and  produce  the  characteris- 
tic physical  evidences.  A  condition  wiiich  should  never 
be  forgotten  is  the  occasional  rupture  of  a  mastoid  abscess 
upon  the  internal  surface  through  the  digastric  fossa.  Here 
local  tenderness  over  the  antrum  may  be  absent,  the  pain 
being  referred  to  the  lateral  cervical  region.  In  the  early 
stages  careful  examination  may  reveal  no  difference  between 
the  corresponding  regions  of  the  sound  and  diseased  side. 
At  a  later  period  a  diffuse,  brawny  swelling  is  made  out 
beneath  the  sterno-cleido-mastoid  muscle,  extending  for  a 
considerable  distance  both  in  front  and  behind  it,  the  limits 
being  poorly  defined.  Deep  pressure  over  the  tip  of  the 
mastoid  elicits  pain,  which  is  frequently  considered  to  be 
neuralgic  in  character,  and  depending  upon  the  middle-car 
lesion.     Rupture  at  this  point  is  rather  characteristic  of  cases 


448 


INFLAMMATION    OF    THE    MASTOID    PROCESS. 


which  have  existed  for  a  long  period,  and  where  the  mastoid 
process  has  undergone  sclerotic  changes  with  obliteration  of 
the  pneumatic  spaces.  It  is  all  the  more  necessary  to  recog- 
nize the  condition  early,  since  from  the  consolidation  of  the 
parts  invasion  of  the  cranial  cavity  is  prone  to  occur.  Occa- 
sionally necrosis  of  the  cervical  vertebrae  will  lead  to  a  mis- 
take in  diagnosis,  but  the  condition  is  so  rare  that  it  sel- 
dom leads  to  error.  A  marked  diminution  in  the  quantity 
of  the  discharge,  with  increased  pain,  should  always  make 
one  suspicious  of  involvement  of  the  mastoid.  In  cases 
of  long  standing  the  pain  may  not  be  localized,  but  dif- 
fuse headache  is  complained  of.  This,  together  with  dimi- 
nution in  the  discharge,  is  sufficiently  characteristic  to  de- 
mand operation  if  other  measures  fail  to  afford  immediate 
relief. 

When  the  intracranial  structures  become  involved  the 
manifestations  already  given  under  symptomatology  will  usu- 
ally be  sufficiently  characteristic  to  lead  the  surgeon  to  recog- 
nize the  condition,  although,  as  stated  before,  the  exact  loca- 
tion of  the  lesion  may  be  a  matter  of  doubt.  Here  local 
tenderness  is  of  considerable  value  in  the  absence  of  other  lo- 
calizing data.  Particularly  in  epidural  abscess  the  most  ten- 
der point  is  usually  over  the  purulent  focus. 

Prognosis. — An  inflammation  of  the  mastoid  is  always  a 
grave  condition.  Following  an  acute  middle-ear  affection  and 
promptly  treated,  the  prognosis  is  usually  favorable.  In  very 
young  children,  as  a  sequel  of  an  acute  infectious  disease,  es- 
pecially scarlet  fever,  the  advance  may  be  so  rapid  as  to  baffle 
all  our  efforts  to  check  it.  In  adults  the  condition  usually  re- 
sponds promptly  to  treatment.  Following  a  chronic  purulent 
otitis  the  outlook  is  more  grave  ;  this  is  particularly  true  of 
cases  that  have  been  neglected  and  which  give  the  history  of 
several  previous  attacks  of  pain  referable  to  the  mastoid  re- 
gion, which  have  either  subsided  spontaneously  or  have  dis- 
appeared under  palliative  measures.  Cases  where  the  perfora- 
tion through  the  drum  men^brane  is  located  in  the  membrana 
flaccida  present  more  extensive  destruction  of  the  osseous 
structures  than  those  in  which  the  loss  of  substance  is  in  the 
membrana  vibrans.  The  mastoid  sclerosis  which  is  frequently 
found  in  such  cases  renders  intracranial  involvement  more 
common.  A  brain  abscess  which  has  developed  and  remained 
latent  for  many  years  may  again  become  active  by  an  acute 


PROGNOSIS— TREATMENT.  449 

exacerbation  of  the  local  process  within  the  tympanum  and 
mastoid. 

Diathetic  conditions  such  as  tuberculosis  and  specific  dis- 
ease also  render  the  prognosis  more  grave.  As  age  advances, 
the  powers  of  resistance  are  diminished,  and  any  local  disease 
becomes  correspondingly  more  serious.  Diabetes  seems  to 
cause  the  parts  to  break  down  with  increased  rapidity,  and  in 
such  patients  not  only  is  the  local, process  extensive,  but  inter- 
current complications  of  an  infective  nature  are  more  com- 
mon. This  should  not,  however,  deter  us  from  operating  as 
early  as  the  local  condition  demands  it,  since  tiiis  measure  af- 
fords us  a  means  of  cutting  short  the  destructive  process. 

With  reference  to  the  gravitv  of  the  mastoid  operation  it 
may  be  said  that  the  procedure  is  in  itself  not  danger(3us. 
Very  few  cases  are  recorded  in  which  the  death  of  the  patient 
can  be  traced  U)  the  operation,  even  although  the  cranial  cav- 
ity may  have  been  accidentally  entered.  An  unfavorable  ter- 
mination following  an  operation  usually  depends  upon  the 
extensive  involvement  found  at  the  time,  and  is  in  no  way 
traceable  to  the  measure  adopted  for  its  relief.  In  sixty-one 
cases  operated  upon  by  the  author,  six  terminated  fatally. 
In  one  case  facial  erysipelas  was  the  cause  of  death.  The 
others  were  suffering  from  intercranial  infection  before  the 
mastoid  was  operated  upon.  The  effect  upon  a  previous 
otorrhoea  is  almost  invariably  favorable  if  a  thorough  oper- 
ation is  done,  and  it  is  safe  to  promise  a  cure  not  only  of 
the  immediate  malady,  but  also  of  the  affection  which  has 
existed  so  manv  years. 

Treatment. — When  seen  early,  an  attempt  should  be  made 
to  abort  the  attack  ;  the  patient  must  be  kept  quiet,  and  usu- 
ally confined  to  his  bed.  The  diet  should  consist  of  fluids 
only,  and  a  brisk  saline  cathartic  administered  at  once. 

If  an  otorrhcca  is  present,  it  must  be  ascertained  whether 
drainage  through  the  canal  is  free,  and  any  bulging  segment 
of  the  drum  membrane  should  be  thoroughly  incised,  the 
original  opening  being  enlarged  by  means  of  a  blunt  knife.  In 
exxcuting  this  measure,  it  is  imperative  that  the  incision 
should  be  extensive,  and  so  placed  as  to  divide  the  numerous 
reduplications  in  the  upper  portion  of  the  tympanic  cavity. 
Even  when  there  is  no  tumefaction  of  the  anterior  mastoid 
wall  presenting  in  the  canal,  I  am  decidedly  in  favor  of  ex- 
tending the  section  through  Shrapnell's  membrane  outward 


450 


INFLAMMATION   OF   THE    MASTOID    PROCESS. 


along  the  superior  wall  of  the  canal  for  at  least  a  quarter 
of  an  inch.  After  free  drainage  has  been  obtained,  frequent 
irrigation  with  a  mild  antiseptic  solution  should  be  practiced 
both  for  cleansing  purposes  and  to  reduce  the  tumefaction  of 
the  parts.  The  application  of  cold  to  the  mastoid  is  a  valu- 
able measure  in  the  early  stages.  It  is  most  conveniently 
employed  by  means  of  the  Leiter  coil,  care  being  taken  that 
the  appliance  is  molded  so  as  to  touch  the  mastoid  at  every 
point.  It  is  not  necessary  to  remove  the  apparatus  when  the 
ear  is  to  be  syringed.  The  coil  should  be  kept  in  position 
continuously  for  at  least  twelve  hours,  and  better  for  twenty- 
four.  At  the  end  of  this  time,  if  local  tenderness  persists,  it 
is  probable  that  an  operation  will  be  necessary.  Under  no 
condition  should  we  employ  cold  for  a  longer  period  than 
forty-eight  hours.  The  internal  administration  of  narcotics 
may  be  advisable  during  the  first  twenty-four  hours,  but  after 
this  time  they  should  be  withheld,  as  they  only  mask  the 
symptoms.  Local  bloodletting  was  formerly  much  employed, 
and  it  can  not  be  denied  that  it  is  efficient  in  some  instances. 
The  amount  to  be  abstracted  should  be  considerable,  and  in 
the  case  of  an  adult  not  less  than  four  ounces  should  be  re- 
moved. The  objection  to  the  procedure  lies  in  the  local  ten- 
derness which  follows,  which  may  be  frequently  mistaken  for 
that  arising  from  the  inflammatory  proces.  There  is  no  objec- 
tion to  its  employment  in  connection  with  the  use  of  the  coil. 
As  a  diagnostic  measure  the  application  of  cold  is  of  value, 
since  neuralgic  pain  is  increased  by  the  cold,  while  the  suffer- 
ing caused  bv  an  inflammatory  process  is  relieved  bv  it.  Tem- 
porary relief  almost  always  follows,  and  herein  lies  the  danger 
of  the  measure  being  abused.  Quite  frequently  spontaneous 
pain  disappears  completely  after  rest  in  bed  and  the  employ- 
ment of  cold  locally  for  forty-eight  hours.  Upon  examination, 
the  condition  of  the  parts  may  not  be  much  changed,  the  canal 
presenting  the  same  tumefied,  swollen  condition  as  before, 
while  pressure  elicits  tenderness.  The  abatement  in  the 
symptoms  will  persist  as  long  as  the  patient  is  kept  quiet,  but 
they  return  when  he  resumes  his  daily  vocation.  This  ex- 
perience has  so  often  fallen  to  my  lot  that  I  never  continue 
the  effort  to  abort  the  attack  for  more  than  forty-eight  hours, 
feeling  certain  if  marked  improvement  has  not  occurred  in 
this  time  that  operative  treatment  will  be  necessary  sub- 
sequently.     The  value   of    Wilde's   incision    has    been  enor- 


TREATMENT. 


451 


mously  overestimated,  and  is  only  admissible  in  children. 
Here  the  cortex  is  so  thin  that  the  cells  may  be  opened  by 
firm  pressure  of  the  knife.  In  the  adult,  any  symptom  indica- 
tive of  the  advisability  of  this  measure  will  become  so  much 
more  marked  within  twenty-four  hours  that  no  doubt  will  re- 
main as  to  the  advisabilitv  of  openin*;  the  mastoid  cells.  It 
is  certainly  unwise  to  subject  the  patient  to  two  operations 
when  one  will  accomplish  the  desired  result.  The  division 
of  the  soft  parts  within  the  meatus  over  the  mastoid  prac- 
tically meets  all  the  indications  of  external  incision,  and  in 
fact  is  much  more  efficacious,  since  depletion  is  more  direct. 
The  temperature  scarcely  calls  for  any  special  measures.  If 
it  is  unusuallv  high  in  the  earlv  stages,  cither  phenacetine 
or  acetanilide  may  be  given  in  hve-grain  doses,  repeated 
hourly  until  fifteen  grains  have  been  taken.  These  drugs 
relieve  pain,  and  at  the  same  time  the  discomfort  which  the 
elevation  of  body  temperature  causes. 

General  headache,  especially  in  young  children,  may  fre- 
quently be  relieved  bv  the  aj)plication  of  the  ice  cap,  and 
from  the  ease  with  which  the  meninges  may  become  involved 
secondarilv,  the  measure  is  of  value.  Failing  to  secure  satis- 
factc^rv  relief  in  f»)rtv-eight  hours,  ojicrative  measures  are  im- 
perativelv  demanded.  Under  no  condition  is  it  wise  to  delay 
the  stej)  longer  than  this  time  in  chronic  cases.  Where  the 
process  ct)mplicates  an  acute  middle-ear  inflammation  in  an 
adult,  or  where  it  is  priniarv,  we  would  naturally  hesitate 
about  resorting  to  \\\\>  measure  at  such  an  caily  period. 
Practically  the  question  never  arises,  lor  in  these  acute  cases 
enough  relief  is  obtained  from  our  milder  measures  to  war- 
rant delay.  As  to  the  particular  plan  to  be  followed  in  the 
operation,  the  weight  of  evidence  seems  to  be  decidedly  in 
the  direction  of  freely  opening  all  the  mastoid  cells,  so  that 
no  infected  area  may  escape  observation.  The  old  method  of 
perforating  the  cortex  by  means  of  the  drill  scarcely  merits 
discussion  at  the  present  day.  Recovery  is  always  tedious, 
and  general  sepsis  a  not  infrequent  complication,  while  the 
otorrhoea  usually  persists. 

When  the  entire  cortex  is  removed  and  every  vestige  of 
softened  bone  taken  away,  while  free  drainage  of  the  middle 
ear  is  established  through  the  artificial  opening,  recovery  is 
prompt  and  uneventful,  while  the  aural  discharge  may  cease 
at  once,  or,  at  most,  by  the  time  the  external  wound  is  healed. 


452  INFLAMMATION    OF    THE    MASTOID    PROCESS. 

Schwartze  *  was  the  first  to  advocate  a  thorough  expos- 
ure of  the  mastoid  cells  and  the  treatment  of  mastoid  caries 
upon  the  principles  of  general  surgery.  In  this  country 
Gruening  has  advocated  the  removal  of  the  entire  cortex  in 
all  cases  and  has  formulated  the  operation  more  exactly  than 
any  other  writer. 

The  operative  technique  is  described  in  the  section  de- 
voted to  operative  surgery. 

*  Arch,  fiir  Ohrenheilk.,  vol.  vii,  p.  157. 


CHAPTER   XXVI. 

intracranial  complications  of  tymtaxic  infla^l\l\tiox. 

Otitic  Meninc;itis. 

The  mcninc^es  may  be  invaded  in  aural  suppuration  cither 
from  the  middle  ear  itself  or  through  the  C()ni])licating  in- 
volvement of  the  mastoid  process.  This  invasion  may  occur 
by  extension  from  caries  of  the  osseous  walls  and  evacuation 
of  pus  into  the  cranium,  or  bv  infection  through  the  numer- 
ous vessels  which  perforate  the  internal  table  of  the  skull. 
In  children  it  is  not  an  uncommon  complication  of  a  suppura- 
tive inflammation  of  the  middle  ear.  The  process  may  affect 
the  entire  surface  or  may  be  localized,  the  favorite  seat  being 
the  basilar  meninges. 

Symptomatology. — This  affection  is  usually  accompanied 
by  high  temperature,  which  remains  constant,  exhibiting  but 
few  fluctuations,  and  varying  from  ioi°  to  105°.  There  is 
severe  headache,  photophobia,  vomiting,  and  localized  or 
general  convulsions.  In  children  general  convulsive  symp- 
toms are  particularly  common,  owing  to  the  high  tempera- 
ture. In  adults  a  basilar  meningitis  does  not  produce  this 
symptom,  but  affects  groujis  of  muscles  supplied  by  the  par- 
ticular nerves  involved  at  their  points  of  exit  from  the  cranial 
cavitv.  These  muscular  contractions  are  succeeded  by  paral- 
ysis as  the  disease  advances.  When  the  basilar  meninges 
are  affected,  the  respiratory  movements  are  changed  in  char- 
acter quite  early,  and  soon  assume  the  peculiar  variety  known 
as  "  Cheyne-Stokes  respiration,"  in  which  there  are  several 
short  efforts  at  inspiration,  followed  by  a  period  of  com- 
plete cessation  of  the  respiratory  movements,  the  lungs  be- 
ing finally  emptied  by  a  long  sighing  expiratory  effort. 
Delirium  occurs  earlv  in  young  subjects,  but  in  adult  life  the 
sensorium  is  often  not  involved  until  quite  late,  and  delirium 
ma}-  not  occur  at  all,  the  patient  slowly  passing  into  a  condi- 
tion of  coma,  in  which  state  he  dies.     The  paralyses  most  fre- 

(453) 


454 


COMPLICATIONS   OF   TYMPANIC    INFLAMMATION. 


quently  met  with  are  those  caused  by  the  involvement  of  the 
third,  fourth,  and  sixth  nerves.  An  implication  of  the  third 
nerve  causes  at  first  contraction  of  the  pupil,  and  later  dilata- 
tion. One  of  the  earliest  symptoms  of  paralysis  is  failure  of 
the  pupil  to  respond  to  light,  it  remaining  dilated  when  ex- 
posed to  a  brilliant  source  of  illumination.  The  involvement 
of  any  of  the  nerves  above  mentioned  will  produce  stra- 
bismus. 

Diagnosis.^The  recognition  of  the  affection  depends  upon 
the  preceding  history,  associated  with  constant  high  tempera- 
ture,  vomiting,  and  headache.  This  group  of  symptoms  can 
be  characteristic  of  no  other  disease  complicating  an  otitis  in 
adult  life.  The  exclusion  of  any  acute  intercurrent  affection 
naturally  depends  upon  the  absence  of  symptoms  character- 
istic of  such  a  disease.  In  children  the  diagnosis  is  much  more 
difficult,  since  anv  acute  infectious  disease  or  a  disturbance 
of  the  gastro-intestinal  canal  will  give  rise  to  exactl}'  the  symp- 
toms  above  mentioned. 

The  cessation  of  the  discharge  from  the  ear  coincident 
with  the  above  manifestations  should  always  render  us  sus- 
picious of  intracranial  involvement,  while  the  appearance  of 
tonic  spasm  of  individual  muscles,  such  as  those  at  the  nape 
of  the  neck,  is  a  valuable  confirmatory  sign.  Photophobia, 
involvement  of  the  ocular  muscles,  the  interference  with  the 
respiratory  movements,  and  subsequently  coma,  render  the 
diagnosis  simple  in  most  cases. 

Prognosis. — Meningeal  infection  is  usually  fatal,  and  yet 
the  results  obtained  by  Macewen,*  who  reports  six  recoveries 
after  operation,  prove  that  death  does  not  always  follow. 

Treatment. — The  application  of  ice  to  the  head  is  agree- 
able, and  may  retard  to  some  extent  the  progress  of  the  in- 
flammation. The  administration  of  large  doses  of  bromide 
of  sodium  or  potassium  is  also  indicated,  as  it  lessens  the 
irritability  of  the  nerve  centres.  Opiates  should  be  avoided, 
but  may  be  necessary  to  relieve  the  intense  pain.  Free  pur- 
gation by  means  of  salines  should  be  resorted  to  at  once.  The 
administration  of  iodide  of  potassium  internally  is  permissible, 
on  the  assumption  of  a  possible  specific  taint,  either  hereditary 
or  acquired.  Surgical  measures  are  to  be  employed,  but  to 
be  of  service  must  be  resorted  to  earlv.     As  the  disease  will 


*  Diseases  of  the  Brain  and  Spinal  Cord,  American  edition,  1893,  p.  329. 


SINUS   THROMBOSIS. 


455 


certainly  prove  fatal  if  it  is  not  checked  by  operation,  the 
surgeon  should  not  hesitate  to  interfere  even  in  cases  which 
are  apparently  hopeless  if  the  diagnosis  is  unquestionable. 

Sinus  Thrombosis. 

The  occlusion  of  one  of  the  large  venous  channels  within 
the  cranium  by  an  infectious  thrombus  is  always  to  be  re- 
membered as  one  of  the  possible  complications  of  acute  or 
chronic  suppuration  within  the  tvmpanum. 

The  free  communication  through  the  mastoid  veins  be- 
tween the  lateral  sinus  and  the  pneumatic  spaces  immediately 
covering  it,  renders  a  suppuration  within  this  cavity  particu- 
larly prone  to  deposit  septic  material  within  the  lateral  sinus. 
Not  only  may  a  sufjpurative  process  within  the  mastoid  be 
complicated  by  this  lesion,  but  a  middle-ear  suppuration 
alone,  without  involvement  of  the  mastoid  structures,  may 
cause  the  condition  as  well.  Here  the  channel  of  infection 
may  be  the  su[)erior  petrosal  sinus  or  some  of  the  smaller 
venous  tributaries.  When  such  a  deposit  takes  place,  the 
first  step  of  the  process  is  the  occlusion  of  the  sinus  by  a  firm 
fibrinous  clot.  The  development  of  pvogenic  bacteria  within 
this  mass  leads  to  general  septic  infection,  by  the  entrance  of 
bacteria  into  the  general  circulation.  The  thrombus  may  re- 
main localized  within  the  sinus  itself,  affecting  but  a  small 
area,  or  it  may  extend  to  the  internal  jugular  vein.  General 
infection  ma/ take  place  through  the  lateral  sinus  from  peri- 
phlebitis, the  outer  cranial  wall,  which  is  deeply  grooved  for 
the  passage  of  the  vessel,  becoming  necrotic  or  carious,  and 
exciting  an  inflammation  of  the  outer  wall  of  the  lateral  sinus, 
lying  in  immediate  contact  with  it.  Tiiis  is  communicated 
to  the  interior  of  the  vessel,  causing  its  occlusion  in  the  man- 
ner above  described.  Such  a  periphlebitis  may  lead  to  erosion 
of  the  venous  trunk  before  its  lumen  is  occluded  by  a  firm 
clot,  and  cause  a  profuse  haemorrhage. 

Provided  life  is  prolonged  for  a  sufficient  period  to  permit 
of  general  infection,  we  find  secondary  purulent  deposits  in 
various  organs  of  the  body.  The  lungs  seem  to  be  the  favor- 
ite site  of  infection,  septic  pneumonia  being  the  most  com- 
mon complication. 

Secondary  brain  abscess  is  also  met  with,  and  secondary 
thrombosis  of  some  of  the  other  venous  sinuses  within  the 
cranium  as  well.     It  is  interesting  to  note  that  the  primary 


456      COMPLICATIONS   OF   TYMPANIC    INFLAMMATION. 

aural  affection  and  the  primary  sinus  thrombosis  may  cause 
secondary  thromboses  and  brain  abscesses  upon  the  opposite 
side.  For  this  reason  much  uncertainty  exists  as  to  the  ulti- 
mate outcome  of  any  operative  procedure  directed  toward 
the  primary  seat  of  affection. 

Symptomatology. — The  symptoms  to  which  this  affection 
gives  rise  are  insidious  in  their  development,  and  may  escape 
notice  for  a  considerable  period.  The  symptom  character- 
istic of  the  involvement  of  one  of  the  large  venous  channels 
is  a  sudden  rise  in  temperature  followed  by  a  spontaneous 
fall  to  normal  or  nearly  normal.  This  may  be  the  only  svmp- 
tom,  and,  unless  the  temperature  is  taken  at  frequent  intervals, 
may  entirely  escape  observation.  The  sudden  rise  in  tem- 
perature— which  is  usually  exxessive,  and  may  reach  104°  or 
106° — is  due  to  the  passage  of  septic  material  into  the  gen- 
eral circulation  at  successive  intervals,  owing  to  the  breaking 
down  of  the  clot  within  the  sinus.  After  this  condition  has 
continued  for  some  time,  symptoms  of  general  sepsis  develop, 
such  as  asthenia,  emaciation,  and  an  ashy  hue  of  the  skin. 
The  rise  in  temperature  is  usually  followed  by  profuse  per- 
spiration. In  the  late  stages  constitutional  depression  accom- 
panies this,  but  when  the  patient  is  in  fairly  vigorous  health,  as 
at  the  onset  of  the  disease,  this  depression  may  be  so  slight  as 
to  escape  observation.  A  severe  rigor  is  not  an  unusual  S3-mp- 
tom,  and  is  met  with  in  many  cases,  but  is  quite  frequently 
wanting.  Where  it  occurs  it  is  of  great  diagnostic  impor- 
tance, but  its  absence  renders  the  exclusion  of  sinus  thrombo- 
sis  by  no  means  certain.  Symptoms  referable  to  the  cranial 
contents — such  as  headache,  local  or  general  convulsions, 
paralysis,  mental  dullness,  or  delirium — arc  absent  in  uncom- 
plicated cases.  Where  met  with  in  connection  with  evidences 
of  sinus  thrombosis,  we  should  always  suspect  the  involve- 
ment of  either  the  cerebral  substance  itself  or  of  secondary 
meningitis  affecting  a  considerable  portion  of  the  brain  cover- 
ings. When  there  is  a  secondary  process  in  some  remote  organ 
from  the  lodgment  of  infectious  emboli,  we  have,  in  addition 
to  the  rise  in  temperature,  symptoms  peculiar  to  the  organ 
involved.  As  stated  above,  these  deposits  occur  most  fre- 
quently in  the  lungs,  and  a  septic  pneumonia  is  the  most  com- 
mon complication.  This  is  of  the  lobular  type,  isolated  areas 
of  the  pulmonary  tissue  becoming  consolidated,  and  cither 
resolving  subsequently  or  breaking  down  with  the  formation 


SINUS   THROMBOSIS— DIAGNOSIS.  457 

of  a  pulmonary  abscess.  The  liver  and  spleen  may  also  be 
the  seat  of  these  deposits,  but  the  symptoms  presented  are 
so  vague  as  to  escape  recognition,  and  the  condition  is  dis- 
covered at  the  necropsy  only. 

Diagnosis. — The  recognition  of  involvement  of  the  sinus 
alone  would  be  an  exceedingly  simple  matter  were  not  com- 
plicating lesions  so  frequently  present.  The  early  recognition 
of  the  condition  is  of  the  greatest  importance,  and  the  one 
means  which  enables  us  to  effect  this  end  is  to  insist  that  the 
temperature  shall  be  taken  at  frequent  intervals — say  every  two 
hours  during  the  day  and  every  four  hours  during  the  night. 
Where  the  temperature  is  taken  but  twice  daily,  the  affection 
may  escape  recognition  for  a  long  time,  during  which  period 
secondary  deposits  may  have  occurred  either  in  the  viscera 
or  in  the  brain  itself,  converting  a  comparatively  simple  con- 
dition into  one  of  extreme  gravity. 

The  second  symptom  of  diagnostic  importance  is  the  de- 
velopment of  an  asthenic  condition  without  sufficient  local 
disturbance,  either  in  the  middle  ear  or  mastoid,  to  fully  ac- 
count for  its  occurrence.  By  exclusion  this  can  only  come 
from  general  sepsis,  and  its  sudden  development  is  indicative 
of  the  convevance  of  the  septic  material  into  the  blood  cur- 
rent throujrh  a  channel  of  considerable  size.  The  occurrence 
of  rigors  and  profuse  perspiration  are  of  great  diagnostic 
value.  The  examination  of  the  ear  or  of  the  mastoid  wound, 
if  an  operation  has  been  performed,  furnishes  practically  no 
information  of  value. 

Prognosis. — A  certain  proportion  of  these  cases  of  pri- 
mary thrombosis  recover  spontaneously,  although  it  is  im- 
possible to  say  how  many  die  subsequently  from  the  develop- 
ment of  a  cerebral  abscess.  Pulmonary  involvement  is  not 
of  necessity  fatal,  the  local  process  gradually  disappearing  if 
the  powers  of  resistance  of  the  patient  are  sufficient.  Death 
usually  occurs  either  from  profound  systemic  infection,  from 
the  development  of  diffuse  meningitis,  from  the  formation  of 
a  cerebral  abscess,  or  from  extensive  pulmonary  involvement. 

Treatment. — The  operative  treatment  proper  in  these 
cases  will  be  discussed  in  the  section  devoted  to  surgery. 
This,  I  believe,  should  always  be  adopted  when  the  diagnosis 
is  certain.  The  only  therapeutic  measures  to  be  employed 
are  those  which  will  most  successfully  combat  the  asthenic 
condition.  The  free  administration  of  stimulants  is  indicated, 
31 


458      COMPLICATIONS   OF   TYMPANIC    INFLAMMATION. 

alcohol  probably  being-  the  best,  as  it  acts  both  as  a  food 
and  as  a  stimulant.  When  superficial  abscesses  develop,  they 
are  to  be  opened  according  to  the  general  rules  of  surgical 
practice.  The  exhibition  of  large  doses  of  quinine  seems  to 
be  of  value  in  diminishing  the  febrile  movement,  thus  curtail- 
inof  the  excessive  tissue  waste.  Particular  attention  should 
be  paid  to  the  nutrition  of  the  patient.  The  systematic  ad- 
ministration of  milk,  eggs,  and  other  highly  nutritious  and 
easily  digested  foods,  should  be  placed  in  the  hands  of  an  ex- 
perienced nurse,  to  aid  the  patient  to  combat  successfully  the 
infectious  process.  Where  the  stomach  becomes  intolerant, 
the  food  should  be  artificially  digested  before  it  is  adminis- 
tered.    Rectal  alimentation  may  be  necessary  in  some  cases. 

Extradural  Abscess. 

This  condition  is  essentially  one  of  localized  purulent 
meningfitis,  in  which  the  vis  medicatrix  naturce  has  limited  the 
suppurative  process  to  a  smaller  area  of  meningeal  surface. 
In  this  condition  we  find  the  meninges  adherent  to  the  inter- 
nal table  of  the  skull,  completely  walling-  in  the  purulent  col- 
lection and  preventing  the  development  of  diffuse  inflamma- 
tion. Most  commonly  an  abscess  between  the  dura  mater 
and  the  internal  tabic  of  the  skull  is  a  complication  of  a 
chronic  suppurative  process  within  the  middle  ear  or  mas- 
toid. The  thin  wall  separating  the  lining  membrane  of  the 
middle  ear  and  mastoid  process  from  the  meninges  becomes 
necrotic.  During  the  period  in  which  this  process  is  taking 
place  a  localized  meningitis  of  a  low  grade  is  developed 
about  the  affected  area,  so  that  when  the  necrotic  portion 
separates,  the  corresponding  dural  area  is  completely  shut  off 
from  the  general  cranial  cavity.  This  evidently  can  not  occur 
when  the  progress  of  the  disease  is  rapid,  the  development  of 
organized  tissue  taking  place  only  after  a  considerable  period 
of  time.  A  similar  localized  meningitis  may  occur  from  the 
lodgment  of  an  embolus  or  from  thrombosis  of  a  venous  tribu- 
tary, or  often  of  one  of  the  larger  sinuses.  For  some  reason 
the  thrombus  does  not  break  down  rapidly,  but  causes  a 
subacute  inflammation  of  the  tissues  inclosing  it,  so  that  when 
ulceration  takes  place  there  is  no  communication  with  the 
general  cranial  cavity. 

Symptomatology. — This  condition  produces  few  symp- 
toms characteristic  of  its  presence.     The  two  most  important 


EXTRADURAL   ABSCESS.  459 

signs  are  severe  and  continuous  headache,  localized  over  the 
affected  area,  a  moderately  elevated  temperature,  seldom 
above  101.5°  or  102°,  which  underc^oes  slight  fluctuations,  but 
seldom  reaches  the  normal  standard.  Localizing  symptoms 
are  rare,  no  portion  of  the  motor  tract  being  pressed  upon. 

When  situated  in  the  cerebellar  fossa,  vertigo  and  vomiting 
may  occur.  Mental  dullness  is  met  with  in  the  last  stages 
without  reference  to  the  location  of  the  abscess,  and  is  prob- 
ablv  dependent  upon  the  increase  in  intracranial  pressure 
from  effusion  into  the  ventricles.  The  chief  diagnostic  symp- 
toms, however,  are  the  temperature  and  the  headache,  which 
continue  in  spite  of  a  free  opening  in  the  mastoid  process. 
The  temperature  is  not  sufficiently  elevated  to  indicate  throm- 
bosis or  meningitis,  this  latter  being  also  excluded  on  account 
of  the  mild  character  of  the  svmptoms,  while  the  absence  of 
any  localizing  manifestations  and  the  elevation  of  temperature 
serve  to  distinguish  it  from  an  abscess  in  the  cerebral  sub- 
stance. The  headache  is  apt  to  be  localized,  and  over  the 
painful  areas  the  parts  are  often  exquisitely  sensitive  to  pres- 
sure. This  sharj)ly  localized  tenderness  is  of  importance  in 
determining  the  location  of  the  abscess. 

Prognosis. — A  collection  of  pus  in  this  situation  may  re- 
main latent  for  a  long  period.  Any  acute  process  involving 
the  middle  ear  or  mastoid  may  excite  it  to  renewed  activity, 
causing  an  acute  diffuse  meningitis  or  rupture  of  the  abscess, 
either  with  evacuation  into  the  cranial  cavity  or  cerebral  sub- 
stance. Death  may  be  caused  by  the  increased  pressure  if 
the  rupture  is  intracranial,  or  external  rupture  occasionally 
takes  place,  with  abatement  of  the  symptoms.  When  the 
abscess  is  recognized  and  evacuated,  recovery  is  the  rule. 
Spontaneous  evacuation  through  the  outer  wall  of  the  cra- 
nium, with  subsequent  favorable  progress,  has  occun-ed  in 
two  cases  observed  by  Knapp.  The  abscesses  opened  near 
the  occipital  protuberance  in  both  cases. 

Treatment. — Internal  medication  should  be  limited  to  the 
administration  of  supporting  and  stimulating  agents.  The 
onlv  curative  measure  is  the  evacuation  of  the  abscess,  the 
technique  of  which  procedure  will  be  described  later. 

Cerebral  Abscess. 

A  localized  purulent  focus  within  the  brain  tissue  may  be 
either  acute  or  chronic  in  its  development.     The  acute  cases 


460       COMPLICATIONS   OF    TYMPANIC    INFLAMMATION. 

are  exceedingly  rare,  while  it  is  probable  that  the  most  com- 
mon cause  of  chronic  cerebral  abscess  is  a  purulent  otitis. 
These  abscesses  may  be  single  or  multiple  ;  they  may  inyolye 
the  cortex  or  the  deeper  regions  of  the  brain,  and  may  be 
limited  to  one  side,  or  may  be  met  with  in  both  cerebral 
hemispheres.  They  may  follow  either  a  simple  inflammation 
within  the  tympanum,  with  the  formation  of  pus,  or  a  similar 
condition  within  the  mastoid,  an  infectious  thrombosis,  or  an 
epidural  purulent  collection.  The  locality  most  frequently 
affected  is  the  temporo-sphenoidal  lobe,  and  the  next  in  fre- 
quency is  the  cerebellum.  Occasionally  a  similar  process  is 
found  in  the  medulla.  As  a  rule,  they  are  situated  rather 
deeply  in  the  cerebral  substance,  and  if  left  to  themselves 
may  rupture  into  the  lateral  ventricles.  Discharge  of  the 
contents  through  the  meninges  occasionally  occurs  where  the 
accumulation  is  superficial,  and  in  rare  instances  the  pus  finds 
its  way  through  a  perforation  in  the  tympanic  roof,  and  ap- 
pears externally  as  a  discharge  from  the  meatus.  An  abscess 
may  remain  latent  for  a  period  of  many  years,  being  excited 
to  renewed  activity  by  the  occurrence  of  an  acute  inflamma- 
tion of  the  region  primarily  involved. 

Examination  of  many  of  these  abscesses  shows  that  the 
fluid  is  sterile,  artificial  cultures  being  entirely  inert. 

Symptomatology. — If  located  so  that  pressure  is  exerted 
upon  the  motor  tract  or  upon  the  motor  area  in  the  cortex, 
localizing  symptoms  occur.  These  are  at  first  of  a  convulsive 
character  if  the  process  is  acute,  but  when  chronic  the  in- 
crease in  pressure  develops  so  gradually  that  the  various 
areas  are  destroyed  completely  without  any  previous  stage 
of  excitation.  Hence  the  paralytic  stage  is  not  preceded  by 
one  characterized  by  convulsive  seizures. 

The  favorite  site  for  the  development  of  this  abscess  is  in 
the  temporo-sphenoidal  lobe,  and  hence  characteristic  local- 
izing symptoms  are  only  produced  when  the  abscess  has  at- 
tained considerable  size,  in  which  case  it  involves  the  speech 
area,  and  produces  either  sensory  or  motor  aphasia.  Located 
within  the  cerebellum,  unsteadiness  in  gait  and  vomiting  con- 
stitute the  characteristic  symptoms,  although  these  do  not 
appear  unless  the  middle  lobe  of  the  cerebellum  is  pressed 
upon.  The  asthenic  symptoms  are  more  indicative  of  the 
affection  than  are  any  special  manifestations.  From  a  rapid 
increase  in  the  size  of  the  abscess,  local  or  general  convulsions 


CEREBRAL    ABSCESS.  461 

may  occur;  the  pulse  may  be  accelerated  in  acute  cases,  the 
relation  between  the  pulse  and  the  temperature  being  the  re- 
verse of  that  characteristic  of  meningitis.  In  the  chronic  cases 
development  is  so  insidious  that  the  hrst  symptom  noticed  is  a 
condition  of  marked  physical  impairment.  The  mental  status 
furnishes  valuable  information  as  well,  the  patient  being  irri- 
table at  times,  while  at  other  times  he  is  either  inattentive 
or  even  somnolent.  This  condition  of  hebetude  gradually 
deepens  to  one  of  coma.  The  temperature  is  seldom  elevated 
above  99° ;  the  pulse  is  usually  normal,  occasionally  intermit- 
tent. Headache  of  a  dull,  diffuse  character  is  complained  of 
in  cases  of  long  standing.  Sometimes  sleeplessness  is  the 
only  symptom  for  which  the  patient  seeks  advice. 

The  termination  of  the  case  is  usually  sudden,  death 
taking  place  from  rupture  into  the  ventricles  or  from  com- 
pression or  destruction  of  the  vital  centres. 

Diagnosis. — In  discussing  mastoid  inflammation,  it  was 
stated  that  the  recognition  of  a  cerebral  abscess  depended 
principally  upon  the  gradual  and  steady  impairment  of  the 
general  health  without  any  sufficient  local  cause,  and,  in  the 
absence  of  symptoms,  pointing  to  either  meningitis,  extra- 
dural abscess,  or  sinus  thrombosis. 

Bergmann,*  in  his  monograph  upon  the  surgical  treatment 
of  intracranial  disease,  asserts  that  the  history  of  otorriinea, 
past  or  present,  together  with  persistent  sleeplessness  and  a 
temperature  remaining  steadily  at  about  99°,  are  sufficient 
indications  for  opening  the  cranial  cavity  for  the  purpose  of 
exploration.  The  experience  of  this  surgeon  would  certainly 
lend  great  weight  to  his  statement  ;  but  in  the  cases  which 
come  under  the  observation  of  the  otologist  we  may  usually 
wait  until  some  localizing  symptoms  develop  or  until  the  con- 
dition of  hebetude  is  well  pronounced  before  we  interfere. 
The  advantage  of  delay  lies  in  the  fact  that  more  precise  in- 
dications as  to  the  particular  location  of  the  abscess  may 
appear  in  the  late  stages,  while  the  danger  to  the  patient  is 
not  materially  increased. 

Complicating  lesions  may  render  the  diagnosis  difficult, 
and  it  is  well  to  bear  in  mind  that  an  otitis  upon  one  side  may 
produce  an  abscess  of  the  opposite  cerebral  hemisphere,  a 
fact  which  still  further  complicates  our  diagnosis. 


*  Himkrankheiten. 


462       COMPLICATIONS   OF   TYMPANIC    INFLAMMATION. 

An  examination  of  the  field  of  vision  may  yield  valuable 
information  in  locating  the  abscess.  The  ophthalmoscope 
may  reveal  the  presence  of  choked  disc,  but  this  appearance 
is  indicative  of  an  intracranial  lesion  simply,  and  is  not  char- 
acteristic of  abscess  alone. 

Prognosis. — Unless  surgical  aid  is  invoked  an  abscess  with- 
in the  brain  substance  must  cause  death.  It  is  proper,  there- 
fore, to  resort  to  surgical  measures  as  soon  as  the  diagnosis  is 
made.  In  some  instances  it  is  wise  to  wait  for  the  develop- 
ment of  symptoms  which  will  indicate  the  situation  of  the  pu- 
rulent collection.  This  interval  will  depend  much  upon  the 
general  condition  of  the  patient,  and  it  is  to  be  remembered 
that  the  operation  is  not  to  be  delayed  until  the  patient  is  too 
much  exhausted  to  react  from  the  operation.  Of  nineteen  cases 
operated  upon  by  Mace  wen,*  eighteen  recovered,  while  Kor- 
ner  f  has  collated  fifty-five  cases  operated  upon,  twenty-nine 
of  which  recovered. 

Treatment. — Nothing  but  operative  interference  is  of  the 
slightest  avail  in  these  cases.  Until  the  surgeon  is  ready  to 
operate,  the  treatment  should  be  directed  to  improving  the 
nutrition  of  the  patient,  so  that  he  may  be  able  to  react  from 
the  operation.  The  technique  of  the  operation  will  be  con- 
sidered in  a  separate  section, 

*  Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal  Cord,  Am.  Ed.,  New  York, 
1893,  p.  333. 

f  Die  otitischen  Erkrank.  des  Hirns,  etc.,  1894,  p.  145. 


SECTION    111. 
SURGERY  OF   THE   CONDUCTIXG  APPARATUS. 


SURGERY    OF 
THE    CONDUCTING    APPARATUS. 


Under  this  section  we  shall  consider  those  procedures  de- 
manded by  various  ])atholo(^ical  conditions  affecting  this  por- 
tion of  the  body.  While  the  term  embraces  all  Operations 
upon  the  auricle,  canal,  tympanum,  mastoid,  and  adjacent  re- 
gions, it  is  evident  that  many  of  these  belong  more  to  the  do- 
main of  general  than  of  special  surgerv.  In  this  section  we 
shall  confine  ourselves  to  those  operations  which  are  not  con- 
sidered in  detail  in  works  on  general  surgery  and  which  are 
of  interest  to  those  engaged  in  special  work. 

For  this  reason  operations  for  the  removal  of  neoplasms  of 
the  auricle  or  for  the  correction  of  deformities  of  the  external 
ear  will  not  be  described.  On  the  other  hand,  the  frequent 
occurrence  of  intracranial  complications  as  the  result  of  aural 
suppuration  renders  the  consideration  of  the  proper  treat- 
ment of  such  affections  imperative. 


CHAPTER   XXVII. 

middle-ear  operations. 

Preparations  Preliminary  to  Operations  upon  the 
Tympanic  Cavity. 

Instruments. — Every  operator  will  from  habit  develop  a 
preference  for  some  particular  form  of  instrument  which  in 
his  hands  will  be  more  valuable  than  one  of  another  pattern. 
Emphasis  should  be  laid  upon  the  fact  that  in  this  branch  of 
surgery,  as  in  all  its  branches,  the  object  to  be  attained  should 
be  kept  in  mind  rather  than  the  particular  appliance  with 
which  it  is  to  be  effected.     In  a  general  way  the  operator 

(465) 


466 


MIDDLE-EAR    OPERATIONS. 


should  have  at  hand  delicate,  sharp  and  probe-pointed  knives, 
of  both  the  curved  and  the  straight  variety  ;  a  number  of  an- 
gular knives,  the  blade  in  each  knife  being  bent  close  to  the 
point,  either  to  an  obtuse  or  right  angle,  according  to  the  par- 
ticular use  for  which  it  is  intended  ;  several  blunt  and  sharp 
hooks,  varying  in  size  and  curve;  curettes  ;  sharp  spoons,  both 
straight  and  angular ;  delicate  forceps  for  removing  detached 
portions  of  tissue,  and  an  ecraseur  for  the  same  purpose.     In 


n 


f     \ 


I 


a  be  d  ^  f  S         ^^  '        J  ^ 

Fig.  123. — Instruments  for  middle-ear  operations. 

addition  to  these,  the  ordinary  speculum  used  in  examination 
will  be  necessary,  together  with  a  large  number  of  cotton  hold- 
ers for  cleansing  the  parts  during  the  course  of  the  operation, 
and  probes,  both  stiff  and  flexible,  for  tactile  exploration.  It 
has  been  a  matter  of  much  discussion  as  to  the  advisability  of 
using  a  straight  knife  or  one  in  which  the  handle  makes  an  ob- 
tuse angle  with  the  shaft  in  operations  of  this  character.  The 
question  should  be  decided  by  individual  experiment.     For 


PREPARATION   OF   THE   EAR.  467 

the  past  two  years  I  have  employed  with  great  success  a  series 
of  instruments  the  blades  of  which  are  forged  from  small  steel 
wire  of  the  correct  size  (Fig.  123).  The  shaft  of  each  instru- 
ment is  provided  with  a  screw  thread  which  enables  it  to  be 
fastened  firmly  into  a  small  handle  made  of  octagonal  brass 
rod.  The  shank  of  the  knife  is  left  malleable,  which  permits 
of  its  being  bent  at  an  angle  with  the  handle,  or  being  used  as 
a  straight  instrument,  according  to  circumstances.  These 
instruments  are  comparatively  cheap,  and  this  is  a  matter  of 
considerable  consequence,  as  the  instruments  become  useless 
after  a  few  operations.  It  is  important  that  all  knives  should 
possess  sufficient  thickness  at  the  back  to  permit  the  blades 
to  be  honed  to  a  keen  edge.  No  cutting  instrument  which  is 
thin  and  spatula-likc  can  be  brought  to  a  fine  edge,  no  matter 
how  much  care  is  exercised.  Too  much  stress  can  not  be  laid 
upon  the  neccssitv  of  having  all  cutting  instruments  as  sharp 
as  care  and  art  can  make  them.  It  may  seem  superfluous  to 
lav  much  stress  upon  this  point,  but  it  is  so  commonly  neg- 
lected in  aural  surgery  that  I  feel  warranted  in  emphasizing 
it  here. 

Concerning  the  preparation  of  the  instruments  ff)r  opera- 
tion, immersion  in  a  boiling  st)da  solution  of  the  strength  of 
one  per  cent  has  in  all  cases  proved  satisfactory.  The  larger 
instruments,  such  as  forceps,  probes,  specula,  etc.,  may  be  al- 
lowed to  remain  in  the  boiling  solution  for  from  three  to  five 
minutes.  Delicate  knives,  however,  should  be  simply  im- 
mersed for  a  moment  and  then  withdrawn. 

Preparation  of  the  Field  of  Operation. — Where  there  has 
been  no  discharge  from  the  external  auditory  meatus  it  usu- 
ally suffices  to  cleanse  thoroughly  the  ear  at  the  time  of  the 
operation  by  means  of  a  solution  of  bichloride  of  mercury  of 
the  strength  of  i  to  3,000  in  equal  parts  of  alcohol  and  water, 
the  lotion  being  applied  by  means  of  a  cotton-tipped  probe. 
The  walls  of  the  canal  should  be  thoroughly  scrubbed  so  as 
to  remove  not  only  any  superficial  deposit  which  may  be  pres- 
ent, but  also  any  desquamated  epithelium  which  may  adhere 
closely.  It  is  better,  however,  to  precede  this  cleansing  by 
having  the  ear  syringed  once  daily  upon  the  two  days  preced- 
ing the  operation  with  an  aqueous  solution  of  the  bichloride 
of  mercury  of  the  strength  of  i  to  5,000,  the  canal  being  oc- 
cluded by  a  pledget  of  sterilized  cotton  immediately  after  the 
irrigation  and  the  pledget  allowed  to  remain  ///  situ  until  the 


^68  MIDDLE-EAR    OPERATIONS. 

next  cleansing.  It  is  a  fact  not  ordinarily  recognized  that 
low  vegetable  organisms,  such  as  various  forms  of  aspergillus, 
are  encountered  quite  frequently  in  the  external  auditory 
meatus,  and  in  no  small  degree  tend  to  excite  infiammalory 
action  after  operative  procedures ;  and  it  is  for  the  purpose 
of  thoroughly  eradicating  these  growths  from  the  field  of 
operation  that  the  above  measures  are  advised,  even  in  cases 
where  the  canal  seems  perfectly  clean.  Where  there  has  been 
an  otorrhoea  of  long  standing  it  is  still  more  necessary  to 
cleanse  the  parts  thoroughly  by  irrigation  with  antiseptic  lo- 
tions before  resorting  to  any  operation.  Thorough  syringing, 
either  once  or  several  times  daily,  according  to  the  amount  of 
discharge,  is  imperative  for  at  least  five  days  before  any  op- 
erative procedures  are  attempted.  The  particular  antiseptic 
chosen  is  a  matter  of  little  importance  ;  the  bichloride-of-mer- 
cury  solution  of  the  strength  of  i  to  5,000,  or  a  dilute  solution 
of  peroxide  of  hydrogen,  or  of  carbolic  acid  i  to  50,  or  a  satu- 
rated solution  of  boric  acid,  are  all  fairly  efficient.  Either  a 
few  hours  before  the  operation  or  immediately  preceding  it 
the  field  should  be  cleansed  with  the  alcoholic  solution  in  the 
manner  mentioned  before. 

Where  proper  attention  has  not  been  paid  to  cleanliness, 
we  frequently  find  in  old  cases  of  otorrhcx^a  that  the  tympa- 
num is  filled  with  exuberant  granulations  due  to  the  effect  of 
heat  and  moisture,  as  well  as  to  the  presence  of  necrosed  bone. 
Cleansing  will  do  much  to  reduce  these  efflorescent  masses, 
but  it  may  be  necessary  to  curette  thoroughly  the  entire  cav- 
ity before  any  further  operative  measure  is  employed,  in  order 
that  the  extreme  vascularity  of  the  parts  may  not  interfere 
with  a  delicate  operation  in  such  a  limited  field.  Where  evul- 
sion is  not  indicated  the  actual  or  chemical  cautery  may  re- 
duce the  granulations  suflficiently. 

Anaesthesia. — Where  the  membrana  tympani  is  present  it 
is  usually  possible  to  perform  the  various  operations  upon  the 
middle  ear  under  local  anaesthesia,  provided  the  patient  pos- 
sesses a  fair  amount  of  self-control.  In  operations  having  for 
their  object  an  improvement  of  the  hearing  it  is  particu- 
larly advantageous  that  the  patient  shall  retain  consciousness 
throughout,  in  order  that  the  results  of  the  various  steps  may 
be  closely  noted.  The  primary  incision  through  the  mem- 
brane is  the  only  step  attended  with  pain,  and  this  is  insignifi- 
cant where  the  knife  is  in  a  proper  condition.    Absolute  anass- 


CLASSIFICATION    OF    OPERATIONS.  469 

thesia  is  obtained  subsequently  by  touching  the  edges  of  the 
incision  with  a  cotton-tipped  probe  moistened  in  a  ten-per-cent 
solution  of  cocaine,  the  probe  being  subsequently  introduced 
into  the  tympanic  cavity  to  anajsthetize  its  lining  membrane. 
Where  the  procedure  has  for  its  object  the  removal  of  carious 
or  necrotic  bone  and  involves  the  necessity  of  curetting  the 
cavity  thoroughly,  general  anaesthesia  should  always  be  em- 
ployed. For  the  division  of  adhesions  in  residual  purulent 
cases  even  local  anaesthesia  mav  not  be  necessary,  as  the  parts 
are  but  slightlv  sensitive. 

The  Position  of  the  Patient.— Since  we  are  accustomed 
to  inspect  the  ear  with  the  patient  either  in  an  erect  or  semi- 
recumbent  posture,  it  is  some- 
what inconvenient  to  operate 
with  the  subject  in  the  hori- 
zontal position.  In  addition 
to  the  distorti(3n  which  the 
parts  suffer,  the  posture  of  the 
surgeon  must  be  cramped  and 
uncomfortable.  These  ctindi- 
tions  are  not  favorable  to  deli- 
cate manipulations.  If  a  gen- 
eral   ana-sthetic    is    necessary 

tlic     upri'-ht     I»OSilion     is     not    '*'"-    >24-Author's   head   and   shoulder 
'       '  ■  .  rest 

available,  but  here  it  is  always 

advisable  to  operate  with  the  shoulders  elevated  so  that  the 
head  can  easilv  be  turned  in  anv  direction.  The  rest  shown 
in  Fig.  124  will  be  found  convenient  in  securing  this  end  if  a 
suitable  operating  chair  or  table  is  n(jt  at  hand. 

Cl.\SSIFRATI()N    of    01'FR.\'U()NS. 

The  various  intratympanic  ojicrations  may  be  classified  as 
follows : 

I.  Operations  iin'ohing  tJic  Mcnibraua    Tyvipani  alone,  com- 
•  prising,  {a)  Perforation  of  the  membrane  (myringotomy),    {b) 

Removal  or  destruction  of  a  segment  of  the  membrane  to 
establish  a  permanent  opening  (partial  myringectomy).  (c) 
Single  or  multiple  incision  of  the  membrana  tympani  to  cor- 
rect anomalies  of  tension.  (We  include  here  section  of  the 
posterior  fold,  or  plicotomy.) 

II.  Operations  involving  tJie  Intratympanic  Soft  Parts. — (a) 
Tenotomy    of   the    tensor    tympani    muscle,     {b)    Section    of 


470 


MIDDLE-EAR   OPERATIONS. 


the  anterior  ligament  of  the  malleus,     (c)  Section  of  adhesions 
resulting  from  suppurative  or  nonsuppurative  inflammation. 

III.  Operations  involving  the  Ossicular  Chain. — {a)  Excision 
of  a  portion  of  the  malleus,  {b)  Disarticulation  at  the  incudo- 
stapedial  joint,  or  division  of  the  long  arm  of  the  incus,  with 
mobilization  of  the  stapes,  (r)  Plastic  operations  for  uniting 
either  the  stapes  or  the  incus  to  the  membrana  tympani 
directly.  (</)  Excision  of  individual  ossicles,  or  of  the  entire 
ossicular  chain. 

I.  Operations  involving  the  Membrana  Tympani  alone. 

{a)  Myringotomy. — A  simple  incision  through  the  drum 
membrane  may  be  performed  either  to  evacuate  fluid,  to 
deplete  the  parts,  or  for  the  purpose  of  exploration.  Former- 
ly the  drum  membrane  was  considered 
so  important  a  structure  that  interfer- 
ence with  it  was  seldom  deemed  justi- 
fiable. Too  much  can  not  be  said  for 
the  purpose  of  correcting  this  error. 
Granting  that  the  instruments,  the  field 
of  operation,  and  the  operator  are  asep- 
tic, an  extensive  incision  through  the 
structure,  even  in  a  state  of  health,  will  be 
followed  by  no  untoward  consequences. 
The  linear  wound  will  heal  completely 
within  twenty-four  hours  and  the  func- 
tion of  the  organ  will  in  no  way  be  in- 
terfered with.  For  whatever  purpose 
the  procedure  is  employed,  it  should  al- 
ways be  remembered  that  the  incision 
should  be  free  rather  than  limited  in  ex- 
tent. Formerly,  for  the  evacuation  of 
fluid  within  the  tympanum  it  was  the 
custom  to  "  puncture  "  the  drum  mem- 
brane with  a  small  lance-shaped  knife 
(Fig.  125).  The  failure  to  secure  speedy 
convalescence  was  then  attributed  to  the  operation.  At  the 
present  day,  when  we  wish  to  evacuate  fluid  from  the  tym- 
panum, the  parts  are  freely  incised  and  the  cavity  emptied, 
and  at  the  same  time  the  vascular  turgescence  is  relieved, 
so  that  the  cut  edges  approximate  closely  and  unite  at  the 
end  of  a  few  hoars. 


Fig.  125. — Myringotome. 


MYRINGOTOMY. 


471 


Operation. — The  field  of  operation  and  the  instruments 
being  thoroughly  aseptic,  the  surgeon  exposes  the  fundus  of 
the  canal  by  the  insertion  of  a  speculum  of  the  proper  size. 
The  site  of  election  for  perforating  the  drum  membrane  varies 
according  to  the  manifestations  in  each  particular  case.  If 
fluid  is  to  be  evacuated  our  incision  should  commence  at  the 
most  prominent  point  and  should  extend  either  upward  or 
downward  through  the  bulging  portion.  Section  is  most 
effective  by  using  the  sharp  knife  shown  in  Fig.  123,  r.  If  the 
bulging  involves  chicflv  the  upper  part  of  the  drum  mem- 
brane the  knife  should  be  carried  into  the  canal  with  the  cut- 
ting edge  upward.  Its  point  is  entered  at  the  apex  of  the 
tumefaction  and  carried  rapidly  through  the  drum  imtil  it  im- 
pinges upon  the  internal  tympanic  wall,  after  which  it  is  made 
to  cut  upward  toward  the  pcrij)herv  as  far  as  may  seem  neces- 
sary (Fig.  97).  As  the  most  prominent  region  is  almost  in- 
variably in  the  posterior  quadrant,  and  usually  in  the  postero- 
superior,  care  must  be  taken  to  avoid  striking  the  long  por- 
tion of  the  incus  with  the  point  of  the  knife.  When  the  pri- 
mary incision  is  made  the  malleus  shaft  can  usually  be  suffi- 
ciently well  made  out  to  be  avoided  ;  but  if  the  knife  impinges 
upon  this  the  operator  will  have  failed  to  secure  a  proper 
opening,  the  resistance  being  firm  and  the  knife  seldom  glid- 
ing off  so  as  to  pass  through  the  membrane  and  evacuate  the 
contents  of  the  cavity.  To  avoid  injuring  the  incus  and  stapes 
it  is  necessary  that  the  operatcjr  should  hold  the  instrument 
delicately  between  the  thumb  and  finger  in  making  the  up- 
ward stroke,  when  contact  with  these  structures  aIII  be  im- 
mediately recognized,  antl  the  blade  maybe  slightly  turned 
so  as  to  avoid  them.  Where  the  most  prominent  area  corre- 
sponds to  the  lower  half  of  the  tympanic  cavity  incision  in  the 
opposite  direction  is  usually  more  convenient.  In  this  case  the 
knife  is  introduced  in  the  canal  with  the  cutting  (t<\gQ.  down- 
ward. Here  no  important  structures  can  be  encountered  and 
the  procedure  is  relatively  simple.  It  is  usually  wise  to  make 
this  incision  somewhat  curvilinear,  following  the  peripheral 
attachment  of  the  membrane,  the  incision  passing  close  to  the 
cartilaginous  ring.  Approximation  is  more  perfect  when  the 
wound  is  located  here  and  cicatrization  correspondingly  more 
rapid.  In  all  cases  attended  with  congestion  or  an  inflamma- 
tory process  the  inner  tympanic  wall  should  be  incised  at  the 
same  time  to  secure  local  depletion.    Regarding  the  absolute 


472 


MIDDLE-EAR   OPERATIONS. 


extent  of  the  incision,  it  is  seldom  wise  that  this  should  be 
shorter  than  one  fourth  of  the  long  diameter  of  the  membrane 
if  lying  in  a  vertical  direction,  or  less  than  one  eighth  of  the 
periphery  if  located  near  this. 

It  is  well  to  remember  that  the  plane  of  the  membrana 
tympani  is  obliquely  placed  to  both  the  horizontal  and  vertical 
transverse  planes  of  the  body.  An  instrument  introduced 
into  the  meatus  and  carried  horizontally  inward  will  frequent- 
ly not  pass  through  the  drum  membrane,  but  will  be  de- 
flected from  its  surface  and  inflict  but  a  superficial  wound. 
This  is  particularly  true  when  the  bulging  involves  the  supe- 
rior segment,  and  in  children.  In  order  to  enter  the  tym- 
panic cavity  the  knife  must  be  passed  not  only  inward,  but 
inward  and  upward,  and  even  after  the  point  has  passed 
through  the  membrane  the  handle  should  be  strongly  de- 
pressed, so  as  to  carry  the  blade  well  up  into  the  cavity.  In 
an  infant  the  plane  of  the  membrane  is  nearly  horizontal,  and 
unless  particular  attention  is  given  to  this  fact  the  operation 
will  be  inefficiently  performed.  It  is  well  in  operating  upon 
a  young  child,  and  even  upon  an  adult  where  the  canal  is  nar- 
row, to  cmphn'  a  curved  knife  (Fig.  87)  rather  than  a  straight 

one,  as  an  extensive  incision  is 
more  easily  made  if  this  is  done. 
Where  myringotomy  is  per- 
formed for  depletion  alone  in 
those  cases  where  the  acute  in- 
flammatory pi'ocess  has  begun 
in  the  vault  of  the  tympanum, 
the  atriiuTi  remaining  free,  our 
success  in  aborting  the  attack 
will  depend  largely  upon  the 
thoroughness  with  which  we 
divide  the  connective -tissue 
structures  lying  in  the  tym- 
panic vault.  In  such  a  case  the 
knife  should  be  introduced  with 
the  blade  lying  in  the  horizon- 


FiG.  126.— Incision  of  Shrapnell's  mem- 
brane in  the  early  stages  of  acute 
purulent  otitis.  (The  continuation 
of   the    incision    upon    the    superior 


wail  of  the  canal  is  indicated  by  the    tal  plane,  the  Cutting  edge  look- 

dotted  linp  \       ^Vati.rol   ^,To  \  r  '  00 

ing  backward  (Fig.  126).     The 


dotted  line.)     (Natural  size.) 


point  punctures  the  drum  membrane  just  above  and  behind  the 
short  process  of  the  malleus,  the  knife  being  passed  upward 
and  inward  and  a  little  backward,  to  avoid  the  body  of  the 


EXPLORATORY  MYRINGOTOMY. 


473 


incus.  The  incision  is  then  carried  horizontally  backward  to 
the  periphery,  when  the  cuttin^;^  edge  of  the  knife  is  turned 
upward  and  the  incision  extended  for  a  short  distance  along 
the  superior  wall  of  the  canal  (as  shown  by  the  dotted  line  in 
Fig.  126).  This  severs  the  numerous  reduplications  of  mucous 
membrane  and  efficiently  depletes  this  region  and  the  lining 
membrane  of  the  mastoid  antrum. 

Exploratory  Myriugotoviy. — When  it  seems  desirable  to 
explore  the  interior  of  the  tympanum,  the  end  is  most  easily 
attained  by  reflecting  a  flap  of 
the  membrana  tympani.  As  the 
region  demanding  particular  in- 
spection is  that  occupied  by  the 
incudo-stapedial  articulation  and 
the  niches  of  the  oval  and  round 
windows,  the  held  of  operation 
lies  in  the  posterior  segment. 
This  has  been  proved  to  be  the 
part  possessing  the  least  tactile 
sensibility,  and  primarv  incision, 
if  located  just  within  the  clear 
membrane  close  to  its  posterior 
border  and  midway  along  the 
periphery,  can  be  made  with 
scarcely  any  pain.  The  knile 
should  possess  so  keen  an  edge  and  so  sharp  a  point  that  it 
will  penetrate  the  delicate  septum  bv  its  own  weight.  The 
puncture  should  be  made  within  the  clear  membrane  to 
avoid  hsemorrhage,  and  especial  care  is  to  be  taken  that 
the  mucous  membrane  over  the  internal  wall  is  not  wounded, 
for  the  same  reason.  After  a  short  incision  has  been  made 
in  this  region  a  ten-per-cent  solution  of  cocaine  is  applied  to 
its  margins  by  means  of  a  cotton-tipped  probe,  after  which 
the  section  is  carried  upward  along  the  peripheral  attach- 
ment to  the  posterior  fold,  then  ftjrward  just  below  this  to  the 
short  process  of  the  malleus,  where  it  again  turns  downward 
and  runs  parallel  with  the  manubrium  and  posterior  to  it  (Fig. 
127).  It  is  usually  necessary  to  repeat  the  process  of  anaes- 
thetizing several  times  before  the  incision  is  completed,  but  if 
this  is  carefullv  done  not  the  slightest  pain  is  experienced. 
The  flap  now  falls  outward  and  the  tympanic  cavity  lies  open 
to  inspection  (Fig.  136).  In  the  great  majority  of  cases  the  in- 
32 


Fk; 


-Kxplorator)'  myringotomy. 
(Natural  size.) 


^74  MIDDLE-EAR   OPERATIONS. 

ciido-stapedial  articulation  will  readily  be  seen,  and  the  de- 
o-ree  of  mobility  of  the  stapes  and  the  amount  of  motion  pos- 
sible at  the  malleo-incudal  joint  can  be  determined  by  manip- 
ulation with  a  cotton-tipped  probe  or  by  passing  a  delicate 
hook  behind  the  descending  arm  of  the  incus.  If  the  round 
window  is  not  exposed,  or  if  the  flap  does  not  turn  readily, 
the  original  incision  may  be  extended  downward  along  the 
posterior  peripheral  margin  as  far  as  the  inferior  pole.  Dis- 
placement of  the  flap  may  not  expose  the  incudo-stapedial  ar- 
ticulation and  the  niche  of  the  round  window  in  some  cases, 
as  these  may  be  covered  by  the  fold  of  the  posterior  pocket 
or  by  certain  irregular  reduplications  of  the  mucous  mem- 
brane. These  folds  may  be  so  delicate  that  they  are  recog'- 
nized  with  difficulty  and  yet  hide  completely  the  landmarks 
within  the  tympanum.  If  the  various  landmarks  are  not  seen 
upon  reflection  of  the  flap,  the  sharp-pointed  knife  should  be 
used  to  make  one  or  two  short  vertical  incisions  through  the 
membrane  over  the  inner  tympanic  wall.  The  edges  of  the 
incisions  separate,  from  the  elasticity  of  the  membrane,  and 
the  landmarks  appear.  The  cavity  having  been  explored  and 
the  indicated  measures  adopted,  the  flap  may  be  replaced  and 
held  in  position  by  a  bit  of  thin  sized  paper  which  has  been 
previously  soaked  in  a  solution  of  bichloride  of  mercury  (i  to 
3,000).  This  paper  dressing  is  introduced  into  the  meatus 
either  on  the  end  of  a  cotton-tipped  probe  or  by  means  of  a 
forceps,  and  is  placed  upon  the  surface  of  the  drum  mem- 
brane, and  by  manipulation  made  to  slide  over  this  until  the 
flap  is  replaced,  when  further  manipulation  carries  the  paper 
disc  over  the  line  of  incision,  sealing  it  and  retaining  the 
edges  in  position  by  its  adhesion  to  the  surrounding  intact 
surface.  At  the  end  of  one  or  two  days  the  healing  process 
is  complete,  and  the  paper  is  subsequently  thrown  out  by 
the  outward  growth  of  the  epithelial  laver  of  the  membrana 
tympani. 

(6)  Partial  Myringectomy. — It  is  seldom  possible,  by  the  ex- 
cision of  any  portion  of  the  membrana  tympani  or  by  destruc- 
tion by  caustic  agents,  to  secure  a  permanent  opening  through 
the  drum  membrane.  When  we  desire  to  determine  what 
the  effect  of  a  permanent  opening  would  be  in  anv  given  case, 
a  partial  myringectomy  will  enable  us  to  attain  this  end,  al- 
though the  opening  will  usually  close  at  some  subsequent 
period. 


MULTU'LK    INCISION    OF    THE    MEMBRANA. 


475 


The  operative  technique  consists  in  the  excision  ol  a  flap 
which  is  to  be  formed  in  the  manner  already  described  in  ex- 
ploratory myringotomy.  If  caustic  agents  are  to  be  used,  a 
minute  drop  of  the  concentrated  sulpiuiric  acid  is  applied,  bv 
means  of  a  cotton-tipped  probe,  to  the  area  chosen  for  per- 
f<jration,  care  being  taken  that  no  acid  in  excess  of  what  is  re- 
(juired  to  saturate  the  cotton,  is  conveyed  into  the  canal.  The 
instrument  is  carried  rapidlv  through  the  canal  and  j>ressed 
against  the  membrane  for  a  lew  seconds,  causing  a  rai)id  ne- 
crosis of  all  the  layers,  the  affected  portion  becoming  of  a  dead- 
white  color.  The  probe  easilv  breaks  down  this  necrotic  tis- 
sue and  enters  the  tympanic  cavitv.  There  is  but  slight  pain, 
and  if  care  is  taken  to  use  but  little  acid  there  is  seldom  any 
reaction.  The  galvano-cautery  mav  be  employed  in  the  same 
manner.  Comparing  these  three  methods,  excision  is  un- 
doubtedly the  safest  f)lan,  but  it  is  the  most  difficult  to  ac- 
complish, the  removal  of  the  small  flap  being  bv  no  means 
easy.     The  small  scissors  shown  in    I'iir.    12S  will    be   found 


Flc.   12S. — Author's  scissors  for  middle-car  operations. 


useful  in  separating  the  flap  when  it  is  attached  bv  a  narrow 
pedicle  only.  When  the  flap  can  not  be  excised,  it  may  be 
folded  upon  the  outer  surface  of  the  membrane,  the  pedicle 
by  which  it  is  attached  being  made  as  narrow  as  i)OSsible. 
Unless  the  flap  is  replaced,  the  opening  will  remain  patent  for 
from  two  to  six  weeks,  during  which  time  the  conditions  are 
much  more  favorable  for  observation  than  where  resort  has 
been  had  to  undue  violence  completely  to  excise  the  flap, 
or  where  the  parts  have  been  irritated  bv  either  an  escharotic 
or  the  actual  cautery. 

(c)  Multiple  Incision  of  the  Monbrana  Tynipani. — Politzer* 
and  Gruber+  both  propose  this  operation,  but  for  exactly 
opposite  conditions,  the  former  advising  it  where  the  mem- 
brana  is  much  relaxed  as  the  result  of  the  cicatrization  of  a 
larger  perforation,  while  the  latter  employs  it  to  relieve  in- 


*  Wien.  med.  NVoch.,  1871,  p.  9.  f  Allg.  Wien.  med.  Ztg.,  1873.  p.  2. 


476 


MIDDLE-EAR    OPERATIONS. 


creased  tension,  the  result  of  an  inflammatory  process.  Gru- 
ber  advises  that  several  incisions  be  made  from  the  centre  of 
the  membrane  toward  the  periphery,  through  the  dense  areas, 
the  adjacent  incisions  being  connected  by  tranverse  cuts,  the 
lines  of  section  forming  the  letter  H.  Where  it  seems  advisa- 
ble to  employ  the  procedure  for  a  relaxed  condition,  it  is  neces- 
sary only  to  divide  the  cicatrix  completely,  or  in  some  cases 
to  excise  a  portion  of  it.  It  would  be  exceptional  to  find  any 
permanent  benefit  from  this  operation,  since  the  newly  formed 
cicatrix  must  soon  become  relaxed. 

Plicotoviy. — The  posterior  fold  of  the  membrana  tympani 
may  be  divided  for  the  relaxation  of  tension,  either  in  the 
direction  of  or  at  right  angles  to  its  long  axis.  When  it  is  to 
be  divided  transversely  the  point  of  the  knife  is  entered  just 
above  the  posterior  fold,  midwa}'  between  its  posterior  ex- 
tremity and  the  short  process  of  the  malleus.  After  piercing 
the  membrane  a  quick  downward  stroke  severs  the  tense  band. 
In  order  that  immediate  reunion  shall  not  take  place  Politzer- 
ization or  inflation  by  means  of  the  catheter  should  be  prac- 
ticed daily  for  four  or  five  days. 

The  longitudinal  section  of  the  fold  needs  no  special  de- 
scription. The  knife  punctures  the  membrane  just  below  the 
fold  near  the  anterior  or  posterior  end  and  divides  horizon- 
tally the  tissues  immediately  below  the  band.  It  thus  severs 
any  radiating  fibres  and  relaxes  the  tension. 

II.   Operations    in    which    the   Various    Muscular   or 
Fibrous    Structures    within    the    Tympanum    are 

DIVIDED. 

{a)  Tenotomy  of  the  Tensor  Tympani  Muscles. — This  proce- 
dure was  proposed  by  Hyrtl,*  although  F.  E.  Weber  f  was 
the  first  to  perform  it  upon  the  living  subject.  The  indica- 
tions for  its  performance  have  been  sufficiently  stated  in  an 
earlier  portion  of  the  volume. 

Since  in  a  sclerotic  condition  of  the  mucous  membrane  of 
the  middle  ear  tactile  sensibilitv  is  much  diminished,  it  is 
usually  stated  that  general  anaesthesia  has  seldom  been  neces- 
sary for  the  performance  of  the  operation.  My  own  experi- 
ence has  been,  however,  that  it  is  less  readily  carried  out  than 
some  of  the  more  complicated  procedures  within  the  tym- 


Topographische  Anatomic.  •(•  Berlin,  klin.  Woch..  1S71,  p    ?74. 


TENOTOMY    OK    THK    TENSOR    TVMl'ANI. 


\ 


panic  cavity,  and  I  believe  that  in  order  to  be  successfully  per- 
formed general  anaesthesia  should  be  induced  in  most  cases. 

There  are  several  methods  of  severing  the  band.  Weber- 
Liel,  and  Cholewa  make  use  of  a  knife  of  special  construction 
for  dividing  the  tendon.  In  this  instrument  the  blade  is  hook- 
shaped  and  the  shaft  of  the  knife  is  fixed  in  an  angular  handle 
so  arranged  that  the  knife  can  be  rotated  ii|)()n  its  long  axis 
by  the  manipulation  of  a  slide  on  the  side  of  the  handle.  The 
tc'chnicjue  is  as  follows:  The  membrana  tvmpani  is  incised  in 
front  of  the  j)rocessus  brevis,  the  hook-shaped  knife  introduced 
into  the  cavity,  and  by  depressing  the  handle  and  carrying  it 
somewhat  forward  the  blade  is  made  to  press  ujion  and  par- 
tially encircle  the  tendon  ;  by  rotating  the  blade 
the  tendon  is  severed.  To  remove  the  knife  the 
blade  is  rotated  to  its  former  position  bv  revers- 
ing the  manipulation.  Forcible  inflation  bv  Po- 
litzer's  method  or  with  the  catheter,  and  the 
insufflation  of  a  little  boric  acid  into  the  canal, 
completes  the  operation.  Most  commonlv  the 
procedure  is  conducted  without  resort  to  so 
complicated  an  instrument  as  the  one  described, 
and  most  oj)erators  ])refer  to  enter  the  tvmpanic 
cavity  behind  the  malleus  handle.  Gruber*  ad- 
vises that  the  tenotome  be  introduced  through 
the  membrane  in  either  the  anterior  or  poste- 
rior segment,  according  to  their  relative  acces- 
sibility. Schwartze.  Pomeroy,  and  Cireen  em- 
plov  a  blunt-pointed  knife  curved  on  the  flat. 
I  lartmann  has  devised  an  instrument  (I'ig.  129) 
which  is  curved  both  on  the  Hat  and  in  its  long 
axis,  the  blade  being  sharp-pointed,  so  that 
when  the  middle  ear  is  entered  the  sharp  point 
of  the  knife  can  be  carried  high  up  into  the 
tvmpanic  cavity  The  position  of  the  p)uncture 
and  the  manipulation  of  the  instrument  after 
the  blade  has  entered  the  tympanic  cavity  will 
varv  according  as  the  tendon  is  to  be  divided 
from  above  downward  or  from  below  upward, 
the  operator  is  allowed  considerable  latitude.  The  technique 
depends  upon  the  conformation  in  each  individual  case.     If 


KiG.  129. — Hart- 
mann's  teno- 
tome (slightly 
enlarged). 

Here  asrain 


*  Lehrbuch  fur  Ohrenheilkunde,  Wien,  1888,  p.  562. 


478 


MIDDLE-EAR    OPERATIONS. 


the  tendon  is  to  be  divided  from  above  downward  the  mem- 
brane is  punctured  immediately  behind  the  short  process, 
and  the  curved  or  angular  blade  is  carried  high  up  into  the 

cavity  by  depressing  the 
proximal  end  of  the  in- 
strument, which  at  the 
same  time  is  carried  a 
little  backward,  causing 
the  blade  to  apply  itself 
closelv  to  the  manubrium. 
The  blade  is  then  rotated 
forward  and  downward 
through  an  angle  of  nine- 
ty degrees,  and  section  is 
accomplished  by  a  slight 
sawing  motion,  down- 
ward   pressure   being  ex- 

FiG.   130. — Tenotomy  of  the   tensor  tympani.  1       1       •  1  •  1 

The  knife  is  shown  above  the  tendon,  which     ertcd     during     the      Wlth- 
is  divided  from  above  downward.    (Natural     (J^awal  of  the  instrument. 

As  the  tendon  is  severed 
the  operator  feels  the  resistance  which  it  offered  suddenly 
overcome,  and  a  sharp  click  is  frequently  heard  at  this  mo- 
ment. To  divide  the  tendon  from  below  upward  the  mem- 
brana  is  punctured  just 
below  and  behind  the 
short  process.  Upon  en- 
tering the  cavity  the  in- 
strument is  advanced  for- 
ward, inward,  and  down- 
ward, the  shaft  remaining 
almost  horizontal,  and 
the  flat  surface  of  the 
blade  closely  applied  to 
the  handle  of  the  malleus 
until  it  has  traversed  the 
breadth    of    the    cavity. 

The     handle     is    then    de-     Fl«-    i3i-T<»notomy   of  tensor  tympani  with 

llartmann  s  knife.     (Natural  size.) 

pressed,     thus     carrying 

the  curved  point  of  the  knife  high  up  in  the  tympanum. 
The  instrument  is  then  withdrawn,  upward  pressure  being 
continually  exerted  and  the  tendon  divided  from  below  up- 
ward.     The    technique    described    presupposes    the    use    of 


DIVISION    Ol'   THE    ANTERIOR    LIGAMENT. 


479 


llartmaiin's  tenotome,  which,  being  shar{)-j)()inted,  is  used 
both  to  puncture  the  membrane  and  to  sever  the  tendon 
(Fig.  131.)  When  a  blunt-pointed  knife  curved  on  the  flat  is 
used,  the  drum  membrane  is  incised  close  to  and  behind  the 
handle  of  the  malleus  with  a  sharp  knife  ;  through  this  open- 
ing the  curved  knife  is  inserted,  its  concavitv  being  directed 
toward  the  manubrium.  The  tendon  is  divided  by  depress- 
ing the  handle  of  the  knife  and  extending  the  incision  upward 
toward  the  short  process  (Fig.  132.)  When  it  seems  desir- 
able to  divide  the  tendon 
through  an  incision  in 
the  anterior  segment, 
the  curved  knife  enters 
the  cavitv  somewhat  be- 
low the  sh(jrt  prc^cess.  It 
is  then  advanced  upward 
and  backward,  the  flat 
surface  of  the  blade  pass-  (  •'• 
ing  closely  along  the 
manubrium  and  severing 
the  tendon  as  the  incis- 
ion is  extended.  Where 
tenotomy  is  deemed  ad- 
visable in  cases  of  resid- 
ual purulent  inflamma- 
tion, a  large  perforation  being  present,  no  preliminarv  in- 
cision is  necessary,  the  knife  being  introduced  through  the 
existing  perforation  ;  the  tendon  is  severed  cither  from  below 
upward,  or  in  the  reverse  direction,  according  to  the  special 
topography  of  the  case. 

{^)  Division  of  tlu  Anterior  I. ligament  of  tlic  Malleus. — This 
measure  was  advocated  bv  Politzer*  in  cases  of  marked  re- 
traction of  the  membrana  tympani,  it  being  found  in  several 
instances  that  tenotomy  of  the  tensor  tvmpani  ah^ne  did  not 
allow  the  parts  to  resume  their  normal  position,  although  this 
was  possible  if  the  anterior  ligament  had  been  severed. 

The  membrane  is  punctured  just  in  front  of  the  short  pro- 
cess with  a  short  curved  knife,  with  the  cutting  edge  directed 
upward.  The  knife  is  carried  inward  almost  to  the  bony  wall, 
when  the  handle  is  depressed,  crowding  the  edge  against  the 


Km;.    132. —  1  cnotoiny   of   icn-.or  tympani    from 
below  upward.     (Natural  size.) 


Diseases  of  the  Ear,  Am.  edition,  Philadelphia,  1883,  p.  379. 


48o 


MIDDLE-EAR    OPERATIONS. 


ligamentous  tissue  in  the  anterior  fold,  which  is  divided  as  the 
knife  is  withdrawn. 

{c)  The  Division  of  Adhesio?is,  the  Resitlt  of  Suppurative  or 
Nonsuppurative  hifiammation. — We  may  divide  these  adhesions 
according  to  their  location  into  two  classes : 

1.  Adhesions  about  the  stapes  itself. 

2.  Adhesions  between  the  malleus  and  incus  and  inner 
tympanic  wall,  or  tense  bands  immobilizing  the  entire  ossicular 
chain,  the  articulations  between  the  various  ossicles  being 
intact. 

When  the  rigidity  depends  upon  adhesions  about  the 
stapes  itself  as  the  result  of  a  purulent  otitis,  the  incudo-sta- 
pedial  articulation  having  been  destroyed,  we  find  the  pelvis 
ovalis  occupied  by  a  mass  of  dense  tissue  which  frequently 
changes  the  appearance  completely.  The  head  of  the  stapes 
may  present  only  as  a  slight  elevation  upon  the  surface  of  the 
mass.  Close  inspection  may  reveal  a  preponderance  of  the 
newly  formed  tissue  along  the  posterior  margin  of  the  pelvis, 
especially  about  the  stapedius  tendon,  which  can  occasionally 
be  seen  as  a  bright  line  running  through  the  mass.  To  see 
the  stapes  or  what  remains  of  it  I  usually  first  incise  directly 
downward  close  to  the  tympanic  ring,  so  as  to  divide  any 
bands  which  may  tend  to  pull  the  stapes  out  of  the  visual  field. 
To  effect  this  the  knife  is  to  be  carried  inward  just  above  the 
fibrous  band  which  we  wish  to  divide,  and  close  to  the  tvm- 
panic  ring,  until  its  point  impinges  upon  the  bonv  inner  wall 
of  the  tympanum  (Fig.  134.)  It  is  then  carried  downward,  the 
point  being  still  kept  against  the  inner  wall,  and  severs  the 
tendon  of  the  stapedius,  together  with  all  adhesions  which 
passed  from  the  ossicle  toward  the  posterior  tvmpanic  wall. 
This  relieves  the  stapes  from  the  pull  of  the  stapedius  muscle, 
and  from  the  tension  of  the  adhesions  which  have  developed  in 
front,  it  comes  more  clearly  into  view.  Care  should  be  taken 
in  passing  the  knife  inward  not  to  carry  it  too  far,  in  case  the 
bony  resistance  is  not  felt  at  the  proper  depth,  for  fear  of  its 
entering  the  vestibule  and  injuring  the  labyrinth.  After  the 
posterior  bands  have  been  severed,  short  radiating  incisions 
are  made,  taking  the  oval  window  as  a  centre  from  which  they 
diverge.  This  allows  the  parts  to  retract,  and  by  local  de- 
pletion favors  the  formation  of  a  thin  cicatrix,  in  place  of  the 
thick  fibrous  deposit.  The  operation  is  completed  by  the  in- 
sufflation of  a  little  boric  acid.     It  may  be  necessary  to  repeat 


DIVISION    OF    ADHESIONS. 


48 1 


this  procedure  several  times  before  the  desired  result  is  ob- 
tained, since  during  cicatrization  other  adhesions  may  form. 
Careful  attention  will  enable  the  surgeon  to  overcome  the 
rigidit}'  permanently  in  a  large  number  of  cases. 

In  the  second  class  of  cases,  where  the  entire  conducting 
chain  is  bound  down,  relaxation  of  tensicjn  is  frequently  ob- 
tainable by  surgical  interference.  In  many  cases  a  large  per- 
foration is  found,  in  the  lower  half  of  the  membrane,  the  mar- 
gins of  the  perforation  may  adhere  to  the  internal  wall  of  the 
middle  ear  throughout  ;  or  this  condition  may  be  contined  to 
the  region  of  the  tip  of  the  malleus  handle.  In  these  last 
cases  the  blunt  knife,  curved  on  the  fiat,  should  be  used  to 
divide  the  fibrous  bands,  or  in  some  cases  vertical  incisions 
mav  be  made  through  the  cicatrix,  or  the  point  of  adhesion 
mav  be  taken  as  a  centre  from  which  these  incisions  shall 
radiate. 

Another  condition,  not  uncommon,  is  where  a  consider- 
able portion  of  the  membrane  is  destroyed,  the  remnant  of 
the  membrane  in  the  upper 
and  posterior  quadrant  be- 
ing thickened  and  tense,  so 
that  its  lower  border,  cor- 
responding to  the  posterior 
fold,  forms  a  dense  fibrous 
band,  crowding  the  under- 
Iving  structures  firmly  to- 
gether, and  sometimes  f)ar- 
tially  hiding  the  stapes  or 
incudo-stapedial  articulation 
from  view.  Section  of  this 
band,  bv  an  upward  incision 
(Fig.  133),  frequently  im- 
proves the  hearing  ;  or  the 
procedure  may  be  advisable 
as  an  exploratory  measure, 
the  retraction  of  the  cut  edges  permitting  an  inspection  of 
the  structures  lying  in  the  pelvis  ovalis,  and  revealing  a  con- 
dition here  which  mav  be  amenable  to  operative  treatment. 

Adhesions  following  a  nonsuppurative  inflammation  will 
usuallv  be  less  amenable  to  operative  treatment  than  those 
developing  in  the  residual  purulent  cases.  The  reason  for 
this  is  that  in  the  nonsuppurative  cases  the  constricting  bands 


Fig.  133. — Incision  of  cicatricial  band  to 
expose  the  incudo-stajjedial  articulation 
or  to  free  the  stapes.     (Natural  size.) 


482 


MIDDLE-EAR    OPERATIONS. 


are  seldom  confined  to  any  one  locality,  but  involve  the  entire 
ossicular  chain  and  the  pelvis  ovalis  as  well.  The  condition 
is  one  demanding  extensive  and  sometimes  repeated  operative 
measures,  and  the  best  results  are  obtainable  by  first  remov- 
ing the  membrana  tympani  and  the  two  larger  ossicles.  This 
procedure  permits  a  thorough  inspection  of  the  pelvis  ovalis 
and  of  the  stapes,  and  enables  the  operator  to  resort  to  re- 
peated surgical  procedures  or  mechanical  measures  for  the 
relief  of  tension  existing  in  this  locality,  while  the  primary 
operation  eliminates  anomalies  in  tension  arising  from  other 
causes. 

III.  Operations  involving  the  Ossicular  Chain. 

(a)  Excision  of  a  Portion  of  the  Manubrium  Mallei  and  of  a 
Large  Part  of  tJic  Membrana  was  proposed  by  Wreden*  in  cases 
where  it  was  deemed  advisable  to  secure  a  permanent  opening 
into  the  tympanum.  The  procedure  has  fallen  into  disuse, 
since  it  does  not  accomplish  the  desired  end.  The  technique 
needs  no  special  description,  consisting  merely  of  making  a 
circular  incision  of  the  desired  size  by  means  of  a  sharp  knife, 
the  umbo  being  taken  as  the  centre.  After  the  section  has 
been  completed,  the  fibrous  lamella  which  it  encloses  will  be 
held  by  the  manubrium  alone,  and  may  be  removed  by  cutting 
through  the  malleus  handle  by  means  of  an  ecraseur,  cutting 
forceps,  or  other  appropriate  appliance. 

{b)  Disarticulation  at  the  Incudo-stapedial  Joint,  or  Division  of 
the  Long  Arm  of  t lie  Incus  and  Mobilization  of  t lie  Stapes. — This 
procedure  is  of  especial  value  in  the  residual  purulent  cases 
where  the  articulation  is  exposed,  or  is  covered  by  a  thin 
cicatrix  only,  through  which  it  is  easily  visible.  It  is  of  less 
value  in  chronic  nonsuppurative  inflammation,  since  the  open- 
ing which  is  made  through  the  membrane  to  expose  the  parts 
soon  closes,  rendering  it  almost  impossible  for  the  surgeon  to 
relieve  by  secondary  operation  any  unfavorable  results  attend- 
ing cicatrization.  Where  the  long  arm  of  the  incus  and  the 
posterior  crus  of  the  stapes  are  exposed,  disarticulation  is 
effected  by  means  of  the  angular  knife  shown  in  Fig.  123,/ 
and  g,  which  is  inserted  behind  the  descending  process  of 
the  incus,  and  made  to  pass  through  the  articulation  by  cut- 
ting downward.     Any  portion  of  the  capsule  undivided  may 

*  Monatsschrift  fur  Ohrenheilkunde,  vol.  i,  p.  22. 


DISARTICULATION  AND  MOBILIZATION  OF  THE  STAPES.    483 

be  severed  bv  inserting  the  point  of  the  knife  below  and  cut- 
ting upward,  and  bv  hooking  the  knife  around  the  anterior 
aspect  of  the  long  process  of  the  incus  and  cutting  downward. 
It  is  usually  advised  that  the  joint  be  opened  from  behind, 
the  resistance 'offered  by  the  stapedius  muscle  rendering  this 
the  simplest  procedure.  While  this  is  theoretically  correct, 
there  are  several  objections  to  its  performance.  Frequently 
the  long  arm  of  the  incus  lies  so  near  the  margin  of  the  ring 
that  considerable  force  is  necessary  to  introduce  the  knife 
behind  it.  If  disarticulation  is  accomplished  before  the  stape- 
dius muscle  is  divided,  the  retraction  of  this  muscle  may  pull 
the  stapes  complete! v  out  of  view  and  render  subsequent  mo- 
bilization impossible.     It  is  advisable,  therefore,  to  divide  the 


Fig.  134. — Division  of  the  stapedius 
tendon  and  of  adhesions  behind  the 
stapes.     (Natural  size.) 


1- !(..  135. —  Disarticulation  at  the  incudo- 
stapedial  articulation.     (Natural  size.) 


Stapedius  tendon  and  the  adjacent  adhesions  as  the  first  step 
of  the  operation.  This  is  done  by  inserting  a  sharp  straight 
knife  behind  and  above  the  head  of  the  stapes,  between  it  and 
the  tympanic  ring,  carrying  it  inward  until  the  point  touches 
the  inner  tympanic  wall,  and  then  cutting  directly  downward 
(Fig.  134).  By  this  procedure  the  stapes,  and  hence  the  ar- 
ticulation, is  released  and  brought  clearly  into  view  by  the 
traction  of  the  tensor  tympani  muscle  and  of  the  cicatricial 
bands  situated  in  the  anterior  part  of  the  cavity.  The  ante- 
rior aspect  of  the  descending  crus  of  the  incus  is  now  in  such 
a  position  that  the  joint  may  be  easily  divided  by  applying 
the  angular  knife  to  it  and  cutting  downward  and  backward 
(Fig.  135),  or  in  some  ihstances  it  may  be  more  convenient  to 


484 


MIDDLE-EAR    OPERATIONS. 


enter  the  joint  from  below,  with  the  point  of  the  knife,  sweep- 
ing the  blade  anteriorly  and  posteriorly  until  the  capsular 
ligament  is  divided.  x\fter  disarticulation  the  process  of  the 
incus  is  pushed  upward  and  forward  to  prevent  reunion. 
The  stapes  is  next  examined  with  a  probe,  the  most  suitable 
instrument  being  a  fine  cotton  holder,  the  tip  of  which  is 
firmly  wound  with  a  delicate  pledget  of  cotton.  If  the  ossicle 
is  rigid,  it  is  to  be  freed  by  passing  the  pointed  knife  about 
the  foot  plate,  dividing  all  adventitious  bands  which  may  be 
found  within  the  pelvis  ovalis,  passing  from  its  walls  to  the 
crura  of  the  stapes.  After  incision,  mechanical  mobilization 
by  means  of  the  cotton-tipped  probe  should  be  effected.  The 
instrument  is  introduced  below  the  stapes  first,  and  an  attempt 
made  to  crowd  the  ossicle  upward  by  a  leverlike  action  of  the 
probe.  The  same  manipulation  is  repeated  from  above  down- 
ward, from  behind  forward,  and  from  before  backward,  care 
being  taken  not  to  fracture  the  crura.  Where  the  incudo- 
stapedial  articulation  is  ossified,  the  long  arm  of  the  incus 
may  be  divided  by  a  stout  scissors,*  the  fragments  being  sepa- 
rated so  as  to  prevent  reunion,  after  which  mobilization  of  the 
stapes  is  carried  out  after  the  manner  described. 

In  chronic  nonsuppurative  cases  Miot  +  advocated  the 
same  procedure,  the  structures  within  the  middle  ear  being 
exposed  by  an  exploratory  incision  along  the  posterior  margin 
of  the  membrana  tympani,  as  alreadv  described  in  the  tech- 
nique of  exploratory  myringotomy.  General  anaesthesia  is 
not  necessary  either  in  the  residual  suppurative,  or  nonsup- 
purative cases. 

Mobilization  in  the  nonsuppurative  cases  is  less  effectual 
if  the  exploratory  incision  is  allowed  to  heal  than  where  a  per- 
manent opening  is  maintained,  either  by  the  removal  of  the 
entire  membrane,  malleus,  and  incus,  or  by  allowing  the  flap  to 
remain  displaced,  although  by  the  latter  procedure  it  is  seldom 
possible  to  secure  a  permanent  perforation.  The  lack  of  success 
when  the  flap  is  replaced  is  due  to  a  recurrence  of  the  condi- 
tion, the  closure  of  the  opening  rendering  it  impossible  to  deal 
with  this  surgically  except  by  repeating  the  original  operation. 

(c)  Plastic  Operatio7is  for  the  Purpose  of  uniting  the  Incus  or 
the  Stapes  to  the  Membrana  Tympani  Directly. — The  object  here 

*  Politzer,  Archiv  fur  Ohrenheilkunde,  vol.  xxii,  p.  122. 
f  Revue  de  laryngologie,  1S90,  p.  49  et  srq. 


REMOVAL    OF    THE    OSSICLES.  485 

is  to  exclude  the  two  larger  ossicles  from  the  physical  process 
of  sound  conduction,  so  that  the  sound  waves  lalling  upon  the 
membrana  tympani  shall  act  immediately  upon  the  stapes. 
Little  success  has  attended  these  procedures,  although  in  ex- 
ceptional  cases  they  may  be  valuable. 

A  triangular  flap  of  the  membrane  is  turned  aside  from 
the  posterior  superior  quadrant,  exposing  the  incudo-stapcdial 
articulation  ;  the  mobility  of  the  incus  is  determined  by  means 
of  a  probe  ;  adhesions  about  the  stapes  are  severed  according 
to  the  rules  already  laid  down  until  this  ossicle  and  the  incus 
move  freely.  The  triangular  flap  is  then  applied  directly  to 
the  long  arm  of  the  incus  and  held  in  place  bv  a  small  pledget 
of  cotton  or  by  a  small  paper  dressing.  If  the  incus  can  not 
be  freed,  disarticulation  at  the  incudo-stapedial  joint  is  per- 
formed and  the  flap  ap])lied  to  the  head  of  the  stapes  instead 
of  to  the  long  arm  of  the  incus. 

{(/)  Rcinoz'al  of  the  Ossicular  Chain  in  its  Iintirity,or  Ronoval 
of  Individual  Ossicles. — Removal  of  the  ossicular  chain  may  be 
attempted  either  for  the  improvement  of  hearing  or  for  the 
relief  of  a  long-continued  suppurative  process,  or  for  both 
conditions.  Since  the  technique  is  somewhat  different,  ac- 
cording as  the  condition  results  from  a  suppurative  or  non- 
suppurative inflammation,  the  operative  procedure  applicable 
to  cases  where  the  membrana  tvmpani  is  intact  will  first  be 
described  in  detail,  after  which  attention  will  be  given  to  the 
particular  variations  demanded  in  cases  where  there  has  been 
destruction  of  the  membrana  tympani  over  a  large  or  small 
area.     We  have  to  consider,  then — 

1.  Removal  of  the  malleus  and  incus. 

2.  Removal  of  the  malleus,  incus,  and  stapes. 

3.  Removal  of  the  stapes. 

If  the  membrana  tvni[)ani  is  |)resent.  this  is  also  removed 
as  completely  as  possible  in  carrying  out  the  first  two  opera- 
tions, while  in  stapedectomv  the  membrane  is  allowed  to 
remain. 

As  early  as  1873  Schwartze*  advocated  the  removal  of  the 
malleus  and  the  membrana  tvmpani  and  disarticulation  at  the 
incudo-stapedial  joint  in  cases  of  nonsuppurative  inflamma- 
tion.    Kessel  +  excised  the  membrana  tvmpani,  malleus,  and 


*  Arch,  fiir  Ohrenheilk.,  vol.  xxii,  p.  128. 
f  Arch,  fur  Ohrenheilk.,  vol.  xiii,  p.  69. 


486 


MIDDLE-EAR    OPERATIONS. 


incus,  and  mobilized  the  stapes  in  a  case  of  complete  stenosis 
of  the  Eustachian  tube,  while  at  an  earlier  date  he  had  dem- 
onstrated that  the  stapes  *  might  be  evulsed  from  the  oval 
window  without  serious  consequences.  In  1885  Lucae  f  re- 
ported fiftj-three  operations  in  nonsuppurative  otitis  media 
in  which  the  membrana  tympani  and  malleus  had  been  re- 
moved and  the  incudo-stapedial  articulation  divided.  In  six 
of  these  cases  the  incus  was  also  taken  away.  From  this  time 
on  the  current  literature  contains  numerous  reports  of  removal 
of  the  ossicles  in  cases  of  nonsuppurative  inflammation  of  the 
middle  ear,  the  procedure  being  followed  by  var3'ing  degrees 
of  success. 

Concerning  the  necessity  of  general  anaesthesia,  it  may  be 
said  that  at  the  present  time  the  entire  ossicular  chain  and  the 
membrana  tympani  may  be  removed  without  the  administra- 
tion of  a  general  anccsthetic  in  patients  having  a  fair  amount 
of  self-control.  No  discomfort  is  experienced  during  the  en- 
tire procedure  except  at  the  moment  of  making  the  initial 
puncture,  and,  when  the  knife  employed  for  the  purpose  is  in 
perfect  condition,  the  incision  through  the  membrana  tympani 
in  the  posterior  segment  just  within  the  cartilaginous  ring  is 
not  painful  and  sometimes  is  not  felt.  When  the  tvmpanic 
cavity  has  been  entered  the  application  of  a  ten-per-cent  solu- 
tion of  cocaine  by  means  of  a  cotton-tipped  probe  renders  the 
subsequent  steps  absolutely  painless.  It  is  necessary  to  pro- 
ceed slowly,  as  the  local  anaesthesia  is  confined  to  a  limited 
area  beyond  the  extent  of  the  incision,  and  as  the  operation 
progresses  the  cocaine  solution  is  to  be  applied  from  time  to 
time  to  the  edges  of  the  wound  and  introduced  into  the  tym- 
panic cavity  through  the  artificial  opening  whenever  the  pa- 
tient gives  evidence  of  feeling  the  manipulations  in  the  slight- 
est degree.  Naturally  this  prolongs  the  operation  ;  but  the 
advantage  gained  of  testing  the  results  of  the  various  steps 
of  the  operation,  together  with  the  increased  delicacy  of 
manipulation  possible  when  the  patient  is  conscious  and  able 
to  maintain  his  head  in  any  position  in  which  it  has  been 
placed,  more  than  compensates  for  the  loss  of  time. 

Technique  of  the  Removal  of  the  Membrana  Tympani  and 
Ossicles  when  the  Membrana  Tympani  is  Intact. — With  the  sharp 


*  Arch,  fur  Ohrenheilk.,  vol.  xi,  p.  199. 
f  Ibid.,  vol.  XX,  p.  22S. 


R4:.M0VAL    OF    THE    OSSICLES. 


487 


knife  (Fig.  123,  e)  an  incision  is  made  through  the  membrana 
tympani  in  the  upper  and  posterior  quadrant,  commencing 
just  below  the  point  where  the  posterior  fold  meets  the  tym- 
panic ring,  and  following  this  curve,  is  carried  downward 
to  about  the  middle  of  the  posterior  border  of  the  ring. 
This  incision  is  made  close  to  the  insertion  of  the  membrana, 
but  should  lie  entirely  in  the  clear  membrane,  for  the  reason 
that  if  this  is  done  no  hcemorrhage  results.  For  the  same  rea- 
son care  must  be  taken  not  to  wound  the  inner  wall  of  the  tym- 
panum with  the  point  of  the  knife,  as  any  bleeding  greatly  ob- 
scures the  field  of  operation  and  renders  the  succeeding  steps 
more  difficult.  The  edges  of  the  incision  are  now  separated 
and  the  incudo-stapedial  articulation  is  usually  clearly  and 
easily  exposed.  If  sufficient  space  is  not  gained,  a  horizontal 
incision  may  be  made  from  the  upper  extremity  of  the  first, 
forward  toward  the  short  process  of  the  malleus,  the  section 
following  the  course  of  the  posterior  fold  and  lying  just  be- 
low it,  thus  avoiding  the  more  vascular  tissues.  If  this  does 
not  give  sufficient  room  the 
incision  may  then  be  carried 
downward  just  behind  the  long 
process  of  the  malleus,  as  in  ex- 
ploratory myringotomy  (Fig. 
127).  In  this  way  a  flap  is 
formed  which,  on  being  turned 
downward,  enables  the  opera- 
tor to  see  the  incudo-stapedial 
articulation  clearly  (Fig.  136). 
The  next  step  is  the  division 
of  the  stapedius  tendon  ;  this 
may  sometimes  be  seen  run- 
ning from  the  neck  of  the  stapes 
backward  and  disappearing  be- 
hind the  tympanic  ring ;  fre- 
quently, however,  the  head  of 
the  stapes  lies  so  close  to  this 
structure  that  the  tendon  can 
not  be  seen  ;  in  such  a  case  the 
pointed  knife  used  in  dividing  the  membrana  tvmpani  is  in- 
serted close  to  the  head  of  the  stapes  and  slightly  above  it 
and  carried  inward  until  the  inner  wall  of  the  tympanum  is 
reached  ;  a  short  cut  downward  is  then  made,  carrying  the 


Fig.  136. — Incudo-stapedial  articulation 
exposed  by  displacement  of  a  flap 
from  the  membrana  tympani.  3, 
Horizontal  incision  at  lower  portion 
of  membrane  ;  2,  The  dotted  line 
indicates  the  incision  severing  the 
peripheral  attachment  of  the  mem- 
brane.    (Natural  size.) 


488  MIDDLE-EAR    OPERATIONS. 

knife  between  the  head  of  the  stapes  and  the  tympanic  ring-, 
while  the  point  is  still  firmly  pressed  upon  the  inner  wall  of 
the  tympanum  (Fig.  134).  In  this  way  the  muscle  is  thor- 
oughly divided.  When  the  tendon  can  be  seen  its  division  is 
perhaps  more  simple  ;  but  in  either  case  the  point  of  the  knife 
should  be  firmly  pressed  against  the  inner  wall  of  the  tym- 
panum, in  order  that  the  tendon  and  anv  adhesions  about  it 
may  be  thoroughly  and  completely  severed. 

As  soon  as  this  has  been  done  the  action  of  the  tensor  tym- 
pani  will  bring  the  incudo-stapedial  articulation  and  the  stapes 
more  clearly  into  view.  The  next  step  is  the  division  of  the 
incudo-stapedial  articulation  which  is  effected  with  the  angu- 
lar knife.  The  knife  is  inserted  into  the  handle  in  such  a  way 
that  the  point  is  directed  backward  and  is  carried  into  the 
tympanic  cavity  in  front  of  the  long  arm  of  the  incus,  and  the 
blade  passed  to  the  inner  side  of  this  process  (Fig.  135);  by 
slight  pressure  backward  the  shaft  of  the  instrument  is  kept 
close  to  the  descending  process  of  the  incus,  while  at  the 
same  time  the  instrument  is  pressed  inward,  so  that  the  an- 
gular blade  will  lie  against  the  internal  tympanic  wall ;  the 
articulation  is  divided  with  a  downward  stroke.  If  fibres  of 
the  capsular  ligament  still  remain  undivided  posteriorly  the 
angular  knife  is  to  be  turned  in  an  opposite  direction,  with 
the  point  directed  forward,  when,  by  passing  it  behind  the 
long  process  of  the  incus,  a  downward  stroke  will  complete 
the  division. 

If  these  steps  have  been  carried  out  as  indicated  it  will  be 
the  exception  if  more  than  a  drop  of  blood  has  been  lost. 

Next,  with  the  pointed  knife,  a  short,  horizontal  incision  is 
made  through  the  membrana  tympani  at  its  most  dependent 
part  close  to  the  insertion  into  the  annulus  tympanicus  (Fig. 
136,  3);  the  pointed  knife  is  quickly  laid  aside  and  the  probe- 
pointed  knife  (Fig.  123,  c)  is  inserted,  and  the  membrane  is 
divided  along  its  posterior  periphery  from  below  upward 
until  the  exploratory  incision  is  encountered.  In  the  same 
manner  the  anterior  segment  of  the  membrane  is  divided  from 
below  upward  with  the  probe-pointed  knife,  the  incision  ex- 
tending as  far  as,  but  not  into,  Shrapnell's  membrane.  (The  in- 
cision is  indicated  by  the  dotted  line,  2,  in  Fig.  136.)  Up  to 
this  point  no  blood  has  been  lost  and  the  field  of  operation 
is  as  clear  as  when  we  started.  There  remains  to  be  divided 
the  membrana  flaccida  and  the  lisfaments  which  bind  the  mal- 


REMOVAL   OF   THE   MALLEUS. 


489 


leus  externally,  in  front  and  behind.  The  pointed  knife  is 
again  used  for  this  section,  which  should  be  made  rapidly. 
The  knife  is  held  so  that  the  flat  surface  of  the  blade  looks 
toward  the  roof  of  the  canal,  the  cutting  edge  being  directed 
backward  ;  the  point  of  the  knife  is  entered  just  above  the 
short  process  of  the  malleus  and  is  pushed  inward  and  up- 
ward, the  handle  being  depressed  so  that  the  shaft  often 
touches  the  margin  of  the  speculum.  In  this  manner  the 
knife  is  made  to  enter  the  fornix  tvmpani  ;  it  is  now  made 
to  cut  its  way  out,  downward  and  backward,  thus  severing 
the  external  and  posterior  ligaments  of  the  malleus  and  di- 
viding the  membrana  flaccida  posteriorly.  The  knife  is  then 
quickly  turned  and  made  to  cut  in  the  opposite  direction, 
being  carried  forward  over  the  short  process,  dividing  the 
anterior  segment  of  the  membrana  flaccida,  some  fibres  of 
the  external  ligament,  and  the  strong  anterior  ligament  of  the 
malleus.  The  malleus  is  now  held  only  by  the  superior  liga- 
ment and  the  tendon  of  the  tensor  tympani,  neither  of  which 
is  strong.  The  h.xmorrhage  from  the  last  incision  may  be  free 
and  may  obscure  the  field,  but  usuallv,  owing  to  the  elevated 
position  of  the  head,  the  upper  part  of  the  field  is  not  obscured, 
and  the  short  process  of  the  malleus  can  be  distinctly  seen. 
The  ossicle  is  quickly  grasped  with  the  forceps  (Pig.  137).  just 
below  the  short  process,  and  bv  pressing  inward  to  dislodge 


Fig.  137. — McKay's  ear  forceps.  (The  blades 
should  be  about  half  an  inch  longer  than  in  the 
forceps  usu::lly  sold  under  this  name.) 


the  neck  of  the  bone  from  the  projection  upon  which  it  rests, 
followed  by  traction  downward  and  then  outward,  the  ossicle 
is  extracted.  No  force  is  required  to  rupture  the  tendon  of  the 
tensor  tympani  or  the  superior  ligament,  as  they  offer  very  lit- 
tle resistance. 

It  will  be  necessarv  now  to  wipe  out  the  blood  which  has 
followed  the  removal  of  the  malleus,  but  in  most  cases  a  single 
pledget  of  cotton  will  dry  the  cavity  completely.     The  incus 
33 


490 


MIDDLE-EAR    OPERATIONS. 


is  next  sought  for,  and,  if  in  sight,  is  grasped  with  the  forceps 
and  removed,  traction  being  at  first  exerted  downward  and 
forward  and  then  outward.  Most  frequently  when  the  incus 
is  in  view  the  long  process  will  be  seen,  not  in  the  normal 
location,  but  lower  down  and  lying  close  to  the  border  of  the 
tympanic  ring — so  close,  frequently,  that  it  is  overlooked,  for 
it  then  apparently  constitutes  a  part  of  the  ring.  Manipula- 
tion by  means  of  a  probe  reveals  its  identity  and  the  ossicle 
can  be  extracted  in  the  manner  already  described.  This  dis- 
placement of  the  incus  downward  and  backward  is  due  to  the 
fact  that  in  the  removal  of  the  malleus  the  capsular  ligament 
binding  the  two  ossicles  together  must  be  ruptured.  The 
incus  itself  is  attached  to  the  tympanic  wall  by  means  of  a 
single  ligament  running  from  its  short  process  to  the  walls  of 
the  fornix  tympani.  Traction  downward  on  the  malleus  dis- 
places the  incus  downward  and  also  revolves  it  backward,  the 
short  process  being  the  fixed  point.  Thus  frequentlv,  after 
the  malleus  has  been  removed,  careful  inspection  of  the  field  of 
operation  fails  to  reveal  any  trace  of  the  incus,  it  having  been 
rotated  entirely  out  of  sight  behind  the  tympanic  ring.  To 
effect  its  extraction  is  not  always  easy,  and  yet  in  cases  where 
there  has  been  no  suppuration  it  will  rarely  happen  that  the 
ossicle  will  escape.  When  not  in  sight  the  long  process  of  the 
incus  can  be  easily  brought  into  view  by  means  of  the  incus 
hooks  (Fig.  123, y  and  k).  These  hooks  are  curved  in  oppo- 
site directions  for  the  right  and  left  ear,  the  concavity  of  the 
curve  looking  anteriorly  in  each  case;  the  instrument  is  in- 
serted into  the  handle  with  its  angular  extremity  directed 
upward.  The  incus  hook  is  introduced  into  the  tympanic 
cavity  and  the  angular  portion  passed  behind  the  tvmpanic 
ring  close  to  the  floor  of  the  canal,  the  hook  being  inserted 
in  such  a  way  that  the  concavity  of  the  hook  looks  upward. 
When  the  angular  portion  of  the  instrument  has  entirely  dis- 
appeared behind  the  ring  the  instrument  is  drawn  outward 
until  it  is  felt  to  press  closely  upon  the  inner  surface  of  the 
tympanic  ring,  when  it  is  rotated  forward,  at  the  same  time 
being  carried  a  little  upward.  Usually  this  manipulation 
swings  the  long  arm  of  the  incus  into  view  (Fig.  138).  The 
difficulty  sometimes  experienced  in  securing  the  incus  usu- 
ally lies  in  the  fact  that  the  operator  is  inclined  to  search 
for  the  ossicle  too  high  up  in  the  t3^mpanum  and  to  forget 
that  the  long  process  lies  close  to  the   margin  of  the  ring  ; 


REMOVAL  OF   THE    INCUS. 


491 


Fig.    13S. — Incus   hook    in    position. 
(Natural  size.) 


the  hook  is  therefore  frequently  carried  too  deeply  into  the 
tympanic  cavity  and  fails  to  engage  the  long  process.  This 
manoeuvre  is  to  be  repeated  several  times  in  case  the  first  effort 
is  not  successful.  If  no  free  body 
is  felt  with  the  hook  it  is  then 
inserted  into  the  tympanum  at 
the  antero-inferior  portion  with 
the  concavity  of  the  hook  di- 
rected posteriorly  ;  the  hook  is 
now  rotated,  sweeping  the  ex- 
tremity which  touches  the  tym- 
panic ring  closely,  backward, 
and  at  the  same  time  somewhat 
upward.  This  manipulation  will 
bring  the  incus  into  view  in  case 
rupture  of  the  posterior  ligament 
of  the  incus  during  the  removal 
of  the  malleus  has  allowed  the 
ossicle  to  fall  into  the  antero- 
inferior part  of  the  tympanic  cavity,  an  accident  which  may 
sometimes  happen. 

If  the  ossicle  is  not  found  in  either  of  these  situations,  the 
hook  should  be  swept  upward  and  forward  through  the  pos- 
tero-superior  and  superior  portions  of  the  tympanic  cavity, 
keeping  it  still  pressed  firmly  against  the  internal  margin  of 
the  ring.  Care  is  to  be  taken  in  this  manipulation  that  the 
hook  does  not  pass  between  the  crura  of  the  stapes  or  frac- 
ture them  as  it  is  carried  forward.  If  the  incus  still  remains 
hidden,  the  hook  having  the  opposite  curve  should  now  be 
carried  into  the  fornix  tympani  with  the  concavity  directed 
backward,  the  angular  portion  of  the  instrument  being 
hooked  behind  the  inner  extremity  of  the  superior  wall  of 
the  meatus.  The  instrument  is  now  rotated  backward,  and 
at  the  same  time  is  carried  downward,  rotation  being  con- 
tinued through  an  angle  of  one  hundred  and  eighty  degrees. 
This  manipulation  will  dislodge  the  incus  in  cases  where  its 
posterior  ligament  is  very  strong,  or  where  the  long  process 
has  been  rotated  far  backward  out  of  reach  of  the  hook. 
After  this  downward  sweep  it  is  well  to  repeat  all  of  the 
steps  for  dislodging  the  incus  in  the  order  named,  as  this  last 
manipulation  may  displace  the  ossicle  downward,  although  it 
may  still  remain  hidden  from  view.     The  objection  to  begin- 


^02  MIDDLE-EAR   OPERATIONS. 

ninof  the  search  in  the  manner  last  mentioned  lies  in  the  fact 
that,  if  the  ossicle  is  already  free  or  nearly  so,  the  manipula- 
tion is  apt  to  displace  it  so  far  toward  the  mastoid  antrum  as 
to  render  it  entirely  inaccessible.  I  have  written  upon  the 
method  of  extracting  this  ossicle  somewhat  at  length,  because 
I  believe  it  to  be  extremely  important  to  remove  it  if  pos- 
sible ;  and  I  feel  certain  that  the  advantages  gained  by  its 
extraction  are  more  than  enough  to  warrant  prolonging  the 
operation  for  this  purpose. 

After  the  incus  has  been  removed,  the  cavity  is  thoroughly 
dried  and  the  region  of  the  round  window  inspected,  Any 
thickening  in  this  situation  should  be  overcome  by  cutting 
away  the  hypertrophied  tissue  if  possible.  Usually,  however, 
we  find  simply  a  thickening  of  the  mucous  membrane  about 
the  fenestra.  Stellate  incisions  bv  means  of  an  ancrular  knife 
(Fig.  123, /and  ^'■,),  introduced  into  the  niche,  mo§t  frequentlv 
relieve  the  tension. 

The  stapes  is  next  inspected  and  its  mobility  tested.  If 
rigid,  all  adhesions  about  it  should  be  divided  and  the  ossicle 
mobilized  with  the  cotton-tipped  probe,  in  the  manner  already 
described  ;  if  its  motion  is  now  free,  the  operation  may  be 
considered  completed.  If,  on  the  other  hand,  the  motion  of 
the  stapes  is  still  impeded,  or  if  the  adhesions  have  been  found 
to  be  so  extensive  that,  after  they  have  been  divided,  cica- 
trization will  probably  render  the  ossicle  rigid  again,  the 
stapes  may  be  removed.  All  soft  tissue  binding  it  down 
should  be  carefully  severed  with  the  sharp  knife  passed 
around  the  foot  plate,  after  which  a  delicate  hook  (Fig.  123, 
b)  is  passed  between  the  crura  and  the  ossicle  is  removed  by 
traction.  It  is  often  more  easy  to  grasp  the  head  of  the  bone 
with  the  forceps  and  remove  it  in  this  way  than  bv  making 
use  of  the  hook. 

In  cases  where  difficulty  is  experienced  in  finding  the 
incus,  and  it  is  deemed  necessary  to  remove  the  stapes — this 
ossicle  being  easily  seen— it  is  often  wise  not  to  delay  the 
removal  of  the  stapes  until  the  incus  is  found,  since,  in  the 
manipulations  necessary  to  displace  the  incus,  the  crura  of 
the  stapes  might  accidentally  be  broken  or  the  head  of  the 
bone  be  so  displaced  as  not  to  be  easily  seen.  Hence,  if  the 
incus  is  not  readily  found,  and  it  has  been  found  advisable  to 
extract  the  stapes,  this  may  be  removed  as  the  second  step 
of  the  operation,  and   the   incus  subsequently  searched   for. 


REMOVAL   OF   THE    INCUS. 


493 


If  the  stapes  is  removed  at  this  stage  of  the  procedure,  care 
must  be  taken  in  searching  for  the  incus  that  the  incus  hook 
is  not  passed  through  the  oval  window,  thus  injuring  the 
labyrinth.  This  may  seem  a  needless  precaution  ;  but  any 
one  who  has  studied  the  parts  upon  the  cadaver  will  appre- 
ciate how  easily  the  incus  hook  can  be  passed  through  the 
thin  membrane  covering  the  fenestra  ovalis.  The  reason  of 
this  lies  in  the  fact  that  the  plane  of  the  oval  window  is  not 
vertical,   but  inclined   downward  and  outward.     When  this 


Fig.  139. — Author's  cutting  forceps  for  the  removal  of  a  portion  of  the  inner  ex- 
tremity of  the  external  auditory  canal. 

opening  is  situated  high  up,  and  is  almost  hidden  by  the  tym- 
panic ring,  the  incus  hook  may  be  easily  carried  under  its 
upper  margin  and  through  the  membrane  covering  the  open- 
ing, the  operator  mistaking  the  resistance  offered  for  that  of 
the  tympanic  ring.  If  the  posterior  wall  of  the  canal  is  closely 
followed  and  the  incus  hook  made  to  enter  the  tympanum 
low  down,  and  is  afterward  applied  closely  to  the  tympanic 
ring,  this  accident  can  not  occur. 


494  MIDDLE-EAR    OPERATIONS. 

In  some  instances  the  margin  of  the  tympanic  ring  hides 
the  stapes  so  completely  that  this  ossicle  can  not  be  seen,  and 
it  is  impossible  to  form  an  intelligent  opinion  as  to  its  condi- 
tion or  to  effect  its  removal.  In  such  an  event  the  margins 
of  the  ring  in  this  situation  may  be  cut  away  by  means  of  the 
forceps  shown  in  Fig.  139.  This  forceps  is  so  constructed 
that  when  open  the  distal  extremity  of  the  lower  blade  can 
be  passed  up  behind  the  tympanic  ring.  Upon  closing  the 
instrument,  the  chisel  blade  cuts  away  a  small  chip  from 
the  overhanging  wall.  By  repeating  this  procedure  enough 
space  can  be  gained  to  permit  of  access  to  the  stapes  and 
oval  window. 

Occasionally  the  foot  plate  of  the  stapes  will  be  found  to 
be  so  firmly  fixed  in  the  oval  window  that  it  can  not  be  loos- 
ened, and  that  after  dividing  all  adhesions  its  removal  is  im- 
possible, the  crura  sometimes  being  broken  in  the  attempt  at 
extraction.  In  such  an  event  the  operator  should  proceed 
with  the  greatest  caution.  All  the  soft  tissues  should  be  care- 
fully removed  from  the  oval  niche  by  means  of  the  angular 
knives  (Fig.  123,/,^)  and  a  delicate  curette  (Fig.  123,^).  If 
the  outline  of  the  foot  plate  can  now  be  made  out,  a  pointed 
knife  should  be  carried  around  its  periphery  in  the  hope  of 
making  an  opening  at  some  point  where  the  union  is  less  firm  ; 
through  such  an  opening  a  delicate  hook  can  be  introduced 
and  a  part  at  least  of  the  foot  plate  brought  awav.  It  com- 
plete ossification  has  taken  place  I  should  advise  the  cautious 
use  of  a  small  guarded  drill,  which  might  be  made  to  perforate 
the  foot  plate  at  its  centre,  after  which  portions  might  be  re- 
moved with  the  hook.  I  have  never  had  occasion  to  do  this 
upon  the  living  subject,  but  should  not  hesitate  to  do  so, 
using,  of  course,  great  care.  It  would  be  possible  to  carry 
out  this  step  without  evacuating  the  perilymph;  but  even  if 
a  small  quantity  of  the  fluid  should  be  lost,  Kessel's  observa- 
tions have  proved  that  no  harm  results.  It  need  hardly  be 
said  that  such  interference  is  justifiable  only  in  cases  where 
absolute  asepsis  has  been  preserved. 

After  all  the  operative  steps  deemed  necessary  have  been 
carried  out,  the  cavity  is  to  be  dried  with  pledgets  of  cotton 
and  a  tampon  of  iodoform  gauze  or  a  long  pledget  of  cotton  in- 
troduced. This  is  carried  completely  into  the  tympanum  and 
should  fill  the  canal  but  loosely.  The  object  of  the  gauze  is 
to  check  any  oozing  which  ma^^  occur  and  to  serve  as  a  drain. 


TREATMENT    AFTER    OPERATION. 


495 


thus  preventing  the  formation  of  a  blood  clot  within  the  mid- 
dle ear;  if  this  is  allowed  to  form  it  may  give  rise  to  consider- 
able pain  by  preventing  the  escape  of  secretii)n  during  the  first 
days  after  the  operation.  If  there  is  much  pain  a  few  hours  after 
the  operation  this  tampon  is  removed  and  the  ear  is  douched 
with  a  warm,  weak  antiseptic  solution  (as,  for  instance,  a  satu- 
rated solution  of  boric  acid  or  a  solution  of  bichloride  of  mer- 
cury, I  to  8,000),  after  which  the  tampon  is  reinserted.  When 
the  odor  of  iodoform  is  objectionable,  sterilized  or  boratcd 
gauze  may  be  used.  This  second  tauipon  is  allowed  to  remain 
in  position  for  twenty-four  hours,  and  in  cases  where  there  is 
no  pain  after  the  operation  the  first  tampon  is  not  disturbed 
for  twenty-four  hours.  This  tampon  is  placed  so  deeply  as  to 
be  out  of  the  reach  of  the  patient,  while  a  pledget  of  cotton  is 
placed  at  the  orifice  of  the  meatus  to  collect  anv  serous  transu- 
date. The  patient  is  allowed  to  change  this  outer  pledget  as 
often  as  it  becomes  saturated,  but  leaves  the  deeper  one  undis- 
turbed. The  subsequent  treatment  depends  upon  the  amount 
of  local  reaction  following  the  procedure.  If  there  is  but  lit- 
tle discharge,  the  cleansing  of  the  car  once  daily  by  the  sur- 
geon, followed  by  the  insufTlation  of  b(jric  acid,  dermatol,  or 
some  kindred  powder,  will  be  all  that  is  necessary.  If  the 
mucous  membrane  over  the  internal  tympanic  wall  appears 
healthy  and  there  is  little  or  no  secretion,  the  best  results  will 
be  obtained  bv  keeping  the  canal  aseptic  by  gently  wiping  the 
walls  with  a  solution  of  bichloride  of  mercury  (i  to  5,000)  in 
fifty-percent  alcohol,  leaving  the  tympanic  cavity  undisturbed. 
If  anv  powder  is  insufflated  it  should  in  these  cases  be  applied 
to  the  walls  of  the  canal  only,  and  should  not  enter  the  tym- 
panum. When  the  middle  ear  is  not  inflamed,  any  interfer- 
ence retards  the  progress  of  the  case  rather  than  favors  it.  If 
the  patient  can  not  be  seen  daily,  as  is  usually  the  case  in  dis- 
pensary practice,  gentle  syringing  of  the  ear  (jnce  or  twice 
daily,  according  to  the  amount  of  discharge,  if  any  appears,  is 
all  that  will  be  required,  but  I  have  never  thought  it  wise  to 
trust  the  insufflation  of  any  powder  to  the  patient.  When  the 
discharge  is  only  slight,  even  the  syringing  is  objectionable, 
and  an  intelligent  patient  may  be  allowed  to  cleanse  the  ear 
by  simply  wiping  it  out  with  a  pledget  of  cotton  wound  upon 
an  appropriate  cotton  holder.  On  the  other  hand,  if  at  the 
end  of  a  week  there  is  still  considerable  secretion,  the  patient 
is  directed  to  instill  a  few  drops  of  a  solution  of  boric  acid  in 


496 


MIDDLE-EAR    OPERATIONS. 


alcohol  of  a  strength  of  twenty  grains  to  the  ounce,  after  each 
syringing.  The  amount  of  discharge  after  the  operation  will 
depend  upon  the  habit  of  the  patient  and  also  upon  the  condi- 
tion of  the  mucous  membrane  of  the  tympanum.  In  cases  of 
advanced  sclerosis  the  amount  is  frequently  insignificant,  espe- 
cially if  the  patient  is  not  of  a  full  habit.  On  the  other  hand, 
when  the  tympanic  cavity  or  the  fornix  tympani  has  been  full 
of  connective  tissue  rich  in  blood  vessels,  the  discharge  fol- 
lowing the  operation  will  be  more  profuse.  It  is  probable, 
also,  that  prolonged  manipulation  within  the  cavity  at  the  time 
of  the  operation  favors  a  more  profuse  discharge,  although 
this  is  certainly  not  true  in  all  cases,  and  should  not  deter  the 
operator  from  doing  a  deliberate  and  thorough  operation. 

I  have  written  somewhat  at  length  about  the  management 
of  the  cases  after  operation  because  I  consider  this  an  impor- 
tant point.  In  a  general  way,  the  less  that  is  done  after  the 
operation,  the  more  likely  we  are  to  obtain  a  permanent  open- 
ing into  the  tympanic  cavity,  a  condition  always  to  be  desired. 
Hence  the  aim  should  be  to  keep  the  ear  clean  with  as  little 
manipulation  as  possible,  and  to  avoid  the  use  of  astringents 
or  caustics  to  stop  the  discharge,  since  they  will  certainly  pro- 
mote the  reproduction  of  the  tympanic  membrane. 

The  amount  of  disturbance  caused  by  the  procedure  de- 
scribed is  very  slight.  Of  forty  cases,  both  purulent  and  non- 
purulent, thirty-five  left  the  hospital  twentv-four  hours  after 
the  operation  and  resumed  their  regular  dailv  work  without 
the  least  trouble,  and  quite  a  number  returned  home  upon  the 
evening  of  the  same  day,  the  operation  having  been  performed 
in  the  afternoon.  Of  course  the  stapes  was  not  removed  in  all 
of  these  cases;  and  when  this  ossicle  is  taken  away  I  prefer  to 
confine  the  patient  to  the  house  for  twenty-four  hours  at  least. 
Yet  in  three  cases  of  stapedectomy  the  patients  returned 
home  in  less  time  than  this  without  any  unpleasant  effects, 
while  in  two  cases  in  which  this  ossicle  was  left  in  situ,  but 
had  been  subjected  to  considerable  manipulation  in  securing 
the  incus,  dizziness  persisted  for  several  davs  after  the  opera- 
tion. As  a  rule,  when  the  two  larger  ossicles  alone  are  to  be 
excised,  the  patient  can  be  assured  that  any  disturbance  suf- 
ficient to  incapacitate  him  for  work  will  not  last  more  than 
twenty-four  hours — an  item  of  importance  among  those  who 
find  it  impossible  to  obtain  a  longer  respite  from  their  dailv 
vocation.    Of  this  we  can  be  as  certain  as  in  allottinsf  the  same 


REPRODUCTION   OF    THE    MEMBRANE.  497 

period  for  the  disappearance  of  the  unpleasant  effects  of  gen- 
eral anaesthesia,  and  the  surgeon  is  justified  in  promising  that 
the  effects  of  the  operation  will  not  detain  the  patient  after  the 
disturbance  due  to  the  anaesthetic  has  passed  away. 

When  the  stapes  is  to  be  removed,  however,  the  dizziness 
may  make  locomotion  difficult  for  a  somewhat  longer  period, 
and  if  there  is  a  probability  that  this  will  supervene  it  is  not 
wise  to  promise  that  this  giddiness  will  not  interfere  with  lo- 
comotion for  several  days,  although  in  many  cases  the  giddi- 
ness will  disappear  rapidly.  If  the  malleus  and  incus  alone 
are  removed  it  will  be  decidedly  rare  for  any  such  disturb- 
ance to  follow. 

I  have  never  met  with  pain  or  severe  local  inflammation  as 
the  result  of  these  operations,  for  the  reason,  1  believe,  that 
perfect  drainage  exists.  In  this  respect  I  feel  certain  that  the 
complete  removal  of  the  ossicles  and  membrane  commends 
itself,  when  compared  with  some  of  the  intratympanic  opera- 
tions in  which  less  positive  violence  is  done  but  in  wiiich  free 
drainage  is  not  secured. 

As  regards  the  partial  or  complete  reproduction  of  the 
membrana  tympani,  my  experience  has  been  that,  as  a  rule, 
the  membrane  will  reform,  although  this  is  not  always  the 
case.  In  dealing  with  this  result  the  removal  of  the  two  larger 
ossicles  is  of  great  advantage.  The  membrane  which  reforms 
is  usuallv  thin  and  not  as  sensitive  as  the  normal  membrane, 
and  its  removal  is  but  a  trivial  measure  both  for  the  patient 
and  surgeon.  Again,  its  reproduction  does  not  always  impair 
the  result  of  the  operation.  In  cases,  however,  in  which,  after 
the  membrane  has  been  reproduced,  the  hearing  becomes 
worse  than  while  a  perforation  was  present,  it  should  be  re- 
moved. General  ana?sthcsia,  in  mv  experience,  has  never  been 
necessary.  The  first  incision  through  the  membrane  is  slightly 
painful,  after  which  a  few  drops  of  ten-per-ccnt  aqueous  solu- 
tion of  cocaine  introduced  into  the  tympanic  cavity  by  means 
of  the  cotton-tipped  probe  renders  the  remainder  of  the  op- 
eration painless.  The  operation  is  best  performed  by  passing 
the  straight  knife  (Fig.  123,  r)  through  the  membrane  close  to 
the  tympanic  ring  and  just  below  the  head  of  the  stapes  and 
dividing  the  posterior  attachment  of  the  membranes  close  to 
the  ring  for  a  short  distance,  great  care  being  taken  not  to 
woimd  the  mucous  membrane  of  the  tympanum.  The  probe- 
pointed  knife  should  then  be  substituted  and  the  attachment 


498 


MIDDLE-EAR   OPERATIONS. 


followed  downward  to  its  lowest  point.  It  will  then  be  found 
that  the  tissue  is  so  relaxed  that  division  of  the  anterior  at- 
tachment is  difficult ;  to  overcome  this  the  sharp  knife  is  again 
passed  through  the  membrane  at  its  lower  part  just  in  front 
of  the  point  where  the  posterior  incision  terminated.  A  little 
pain  is  usually  experienced  from  the  incision,  but  it  is  only 
momentary.  The  anterior  attachment  is  now  divided  from 
below  upward  with  the  blunt  knife  until  the  incision  meets 
that  which  severed  the  posterior  attachment.  Usually  the  re- 
laxation interferes  with  the  complete  section.  The  membrane 
is  now  held  by  a  thin  strip  of  tissue  above  and  below.  A  touch 
with  the  sharp  knife  severs  these  attachments  or  weakens  them 
to  such  an  extent  that  the  entire  membrane  may  be  easily  re- 
moved with  the  forceps.  If  it  is  too  firnily  held,  the  small  scis- 
sors (Fig.  128)  will  be  found  useful.  The  procedure  is  so  sim- 
ple that,  if  attention  is  given  to  secure  an  aseptic  condition  of 
the  instruments  and  field  of  operation,  no  reaction  results.  The 
operation  may  safely  be  performed  at  the  office  of  the  physi- 
cian and  the  patient  at  once  allowed  to  resume  his  usual  duties. 
It  is  well  to  protect  the  ear  bv  the  insertion  of  a  cotton  pledget 
which  need  not  be  worn  for  more  than  forty-eight  hours  after 
the  removal  of  the  new  membrane.  After  this  it  is  well  for 
the  patient  to  occlude  the  meatus  with  a  cotton  pledget  when 
out  of  doors.  At  the  end  of  five  or  six  davs  no  protection  is 
necessary.  The  patient  should  be  cautioned  against  taking 
cold  ;  but  further  than  this  no  special  precautions  are  to  be 
advised.  The  procedure  is  not  likely  to  be  followed  by  any 
discharge,  and  all  syringing  of  the  ear  is  to  be  avoided  unless 
pain  or  profuse  discharge  supervene,  as  disturbing  the  parts 
in  any  way  may  excite  enough  reaction  to  cause  a  reproduc- 
tion of  the  membrane. 

One  point  is  worthy  of  special  attention,  and  that  is  that 
the  removal  of  a  membrane  which  has  formed  after  operation 
should  not  be  undertaken  until  all  traces  of  inflammation  have 
disappeared.  The  surgeon  must  wait  until  the  newly  formed 
tissue  is  pearly  white  and  glistening  and  until  the  mucous  lin- 
ing of  the  tympanum  has  also  assumed  its  normal  condition, 
as  evidenced  by  the  absence  of  redness,  engorgement  of  its 
vessels  being  easily  made  out  through  the  thin  cicatricial  mem- 
brane. If  this  rule  is  not  observed  the  operation  will  be  more 
painful,  and  reproduction  is  almost  certain.  If  the  membrane 
reform  again,  a  second  or  third  removal  is  still  more  simple,  as 


TREATMENT   OF   SECONDARY    MEMBRANE. 


499 


the  density  of  the  tissue  is  less  each  time  that  it  is  reproduced. 
In  one  case  this  was  so  marked  that  after  the  first  incision  the 
edges  of  the  wound  retracted  so  widely  that  it  was  possible 
to  remove  only  a  minute  portion  of  the  new-formed  tissue,  and 
yet  the  tympanum  was  freely  exposed,  and  no  reproduction 
has  followed  at  the  end  of  several  months. 

In  plethoric  individuals  a  persistent  reproduction  of  the 
membrana  tympani  after  excision  can  be  prevented  bv  a  re- 
striction of  the  diet  for  a  few  weeks  previous  to  and  following 
the  secondary  removal  of  the  structure.  This  is  suggested 
by  Sexton,*  and  I  have  proved  its  efficacv. 

In  certain  instances  it  mav  be  found  that  the  new  mem- 
brane has  become  adherent  to  the  inner  wall  of  the  tympa- 
num, thus  rendering  its  complete  removal  difficult.  In  one 
such  case  in  which  the  stapes  had  been  left  in  situ,  the  hearing 
remaining  impaired,  apparently  on  account  of  the  stapes  being 
bound  down  by  the  newly  formed  membrane,  this  was  divided 
first  behind  the  head  of  the  stapes  and  the  incision  was  car- 
ried downward  close  to  the  tympanic  ring  for  a  distance 
equal  to  about  one  third  its  posterior  margin.  The  stapes 
then  lay  free,  while  in  front  there  was  a  flap  attached  by  adhe- 
sions to  the  inner  tympanic  wall ;  this  flap  was  turned  forward 
and  the  underlying  wall  of  the  tympanum  was  scarified,  after 
which  the  flap  was  replaced  and  pushed  down  upon  the  wall 
of  the  middle  ear,  care  being  taken  that  the  free  margin  lay 
below  the  tympanic  ring.  Adhesion  at  once  resulted,  leaving 
the  stapes  projecting  into  the  canal,  while  the  tympanic  cavity 
was  largely  obliterated  from  the  adhesion  of  the  membrane  to 
its  inner  wall.  Thus  the  middle  car  was  thoroughly  {)r()tcctcd 
by  a  cutaneous  covering,  while  the  parts  essential  to  audition 
remained  accessible  for  further  operative  procedure.  The 
patient,  though  better,  is  still  under  treatment,  and  I  hope  for 
still  further  improvement  following  the  division  of  remaining 
bands  which  partially  fix  the  stapes.  It  may  be  advisable  in 
certain  cases  to  preserve  the  anterior  portion  of  the  membrana 
tympani  in  removing  the  malleus  and  incus,  and,  after  scarifi- 
cation of  the  inner  wall  of  the  tympanum,  to  attempt  to  secure 
adhesion  of  the  anterior  segment  of  the  membrana  to  this 
structure.  In  this  manner  we  might  shut  off  the  anterior 
part  of  the  tympanic  cavity  from  the  posterior  portion  which 

*  The  Ear  and  its  Diseases,  New  York,  1889,  p.  392. 


500 


MIDDLE-EAR   OPERATIONS. 


contains  the  parts  especially  concerned  in  audition.  The  pos. 
terior  portion  would  become  covered  by  epithelium  from 
the  surface  of  the  membrana  tympani,  and  the  objection  of 
having  an  exposed  mucous  surface  would  be  avoided.  We 
could  by  care  secure  a  thin  epithelial  covering  for  the  round 
and  oval  windows,  the  stapes  being  removed  or  not,  according 
to  indications.  I  have  never  performed  the  operation  with 
this  object  in  view,  but,  from  the  fact  that  Nature  occasionally 
succeeds  in  doing  this  unaided,  it  may  not  be  out  of  place  to 
suggest  it  here  as  worthy  of  a  trial. 

Tcchniqiie  of  Operation  where  the  Membrane  is  Partially  or 
almost  Completely  Destroyed. — Where  the  ossicles  are  to  be  re- 
moved for  the  relief  of  a  purulent  inflammation  general  an- 
aesthesia should  be  employed,  since  removal  of  the  ossicles 
alone  constitutes  but  a  small  part  of  the  operation.  The 
pathological  process  is  seldom  confined  to  these  structures, 
but  has  involved  as  well  the  bony  walls  of  the  tympanic  cav- 
ity, and  it  becomes  necessary  to  curette  thoroughly  the  entire 
space  if  the  process  is  to  be  permanently  checked.  In  these 
cases  also  the  malleus  and  incus  are  frequently  destroyed  in 
large  part,  nought  but  minute  fragments  remaining.  To  se- 
cure these  fragments,  prolonged,  and  sometimes  forcible,  ma- 
nipulation becomes  necessary,  and  a  thorough  operation  is 
possible  only  under  general  ana?sthcsia. 

When  a  purulent  inflammation  has  resulted  in  the  destruc- 
tion of  a  considerable  portion  of  the  membrana  tympani,  the 
method  of  procedure  must  be  modified  to  a  certain  extent. 
In  some  of  these  cases  we  shall  find  the  lower  portion  of  the 
membrana  wanting,  the  membrana  fiaccida  thickened  and 
highly  vascular,  binding  the  ossicles  down  and  concealing 
them  more  or  less  completely.  We  may  be  able  to  recognize 
by  inspection  only  the  prominent  short  process  of  the  malleus 
and  a  portion  of  the  manubrium,  the  latter  lying  almost  hori- 
zontal, its  tip  bound  firmly  to  the  upper  part  of  the  inner 
tympanic  wall.  Behind  the  short  process  examination  with  a 
probe  reveals  the  incus  and  stapes  as  present,  but  whether  in 
their  entirety  or  not  can  not  be  determined.  In  other  cases, 
while  there  may  have  been  extensive  destruction  of  the  mem- 
brana tympani,  the  posterior  superior  segment  is  covered  with 
a  thin  cicatricial  membrane,  through  which  the  incudo-stape- 
dial  articulation  is  plainly  seen,  or  this  joint  may  be  com- 
pletely exposed,  no  covering  being  present.    My  rule  has  been, 


TECHNIQUE    IX   SUPPURATIVE    CASES.  501 

in  all  cases  where  the  incudo-stapedial  articulation  is  visible, 
or  where  this  reo^ion  is  covered  by  a  nonvascular  membrane 
the  division  of  which  will  not  lead  to  annoying  hcumorrhage, 
to  divide  first  the  stapedius  muscle  and  then  the  incudo- 
stapedial  articulation  in  the  manner  described  when  consider- 
ing the  method  of  operation  in  cases  in  wiiich  the  mcmbrana 
is  intact.  When,  however,  it  is  evident  that  an  incision  in 
this  region  will  be  followed  bv  haemorrhage,  such  a  step  serves 
only  to  complicate  the  operation,  as  the  bleeding  will  render 
it  impossible  to  see  the  incudo-stapedial  joint,  much  less  to 
disarticulate  with  certainty,  and  will  frcquentlv  comj)letely 
obscure  the  field  of  operation,  hiding  even  that  most  promi- 
nent and  important  landmark,  the  short  process  of  the  mal- 
leus, so  that  considerable  difficult v  mav  be  experienced  in 
removing  even  this  ossicle.  Exi)erience  shows  us  that  when 
this  condition  is  j)resent  there  is  very  little  hasmorrhage  after 
the  membrana  flaccida  has  been  ctimpleteiy  freed  from  its 
attachments  and  removed,  together  with  the  malleus.  Our 
first  step,  then,  will  be  to  insert  the  straight  poinleil  knife 
above  the  short  process,  pushing  it  inward  and  ui)war(l  until 
the  inner  wall  of  the  tympanum  is  encountered  ;  it  is  then 
made  to  divide  rapidly  the  attachments  of  the  remnant  of  the 
membrane  to  the  tympanic  ring  bv  directing  its  edge  back- 
ward and  incising  close  to  the  margin  of  the  ring;  without 
removing  it  from  the  wound,  the  edge  is  turned  in  the  oppo- 
site direction  and  divides  the  anterior  attachments.  In  cut- 
ting backward,  the  operator  must  bear  in  mind  that  the  in- 
cudo-stapedial articulation  has  not  been  severed,  and  in  this 
region  as  little  force  as  possible  should  be  used.  For  tiiis 
reason,  also,  the  posterior  incision  should  be  made  first  as 
above  directed.  Almost  immediately  the  fundus  of  the  canal 
fills  with  blood,  but  for  a  few  seconds  at  least  the  short  pro- 
cess is  plainly  visible  ;  and  if  examination  has  shown  us  that 
the  manubrium  is  not  firmlv  bound  to  the  promontor}',  the 
malleus  is  at  once  seized  with  the  forceps  just  below  the  short 
process  and  removed  in  the  manner  already  described.  If, 
however,  firm  adhesions  are  known  to  exist,  or  if  the  mal- 
leus is  found  to  be  firmh-  fixed  on  grasping  it  with  the  for- 
ceps, no  force  should  be  used  to  effect  its  removal,  but  the 
canal  should  at  once  be  tamponed  firmly  with  cotton  bv  car- 
rying an  elongated  plug  into  the  tympanic  cavity  with  the 
forceps  and  pressing  it  firmly  upon  the  tympanic  wall,  the 


502  MIDDLE-EAR   OPERATIONS. 

remainder  of  the  plug  being  then  forced  inward.  Upon 
this  tampon  a  second  and  third  are  crowded  until  there  is  no 
bleeding  about  the  plugs.  H  this  packing  is  allowed  to  re- 
main in  position  for  a  few  moments  and  then  removed  with 
the  forceps,  the  held  of  operation  will  be  found  to  be  dry,  the 
bleeding  having  been  entirely  checked.  Any  given  area  can 
be  more  completely  cleansed  by  touching  it  with  a  small 
pledget  wound  upon  a  cotton-holder.  The  adhesions  binding 
the  malleus  to  the  promontory  can  now  be  divided  with  the 
blunt  knife  curved  on  the  flat,  after  which  the  ossicle  is  re- 
moved by  means  of  the  forceps.  If  the  malleus  is  still  firmly 
fixed,  manipulation  by  means  of  the  probe  will  determine  the 
situation  of  the  undivided  attachments  and  their  section  can 
be  effected. 

When  it  has  been  possible  to  divide  the  incudo-stapedial 
articulation  as  the  initial  step,  I  frequently  remove  the  malleus 
in  the  manner  described  as  the  second  step  of  the  operation,  in 
place  of  the  first,  after  freeing  the  remnant  of  the  membrane 
from  its  peripheral  attachments  below,  anteriorly  and  posteri- 
orly. This,  of  course,  applies  to  cases  in  which  the  greater  por- 
tion of  the  tympanic  membrane  has  been  destroved.  When 
only  a  comparatively  small  portion  of  the  mcmbrana  vibrans  is 
wanting  and  excision  is  deemed  propicr,  it  may  be  well,  after 
dividing  the  incudo-stapedial  articulation,  to  sever  the  pe- 
ripheral attachments  of  the  membrane  from  below  upward  by 
means  of  a  blunt  knife  introduced  through  the  perforation. 
As  a  rule,  however,  so  many  adhesions  exist  between  the 
inner  tympanic  wall  and  the  lower  portion  of  the  membrana 
that  such  a  procedure  is  unadvisable.  Moreover,  the  parts 
are  frequently  so  vascular  that  the  attendant  bleeding  may 
complicate  the  more  important  part  of  the  procedure — the 
division  of  the  superior  attachments  and  the  removal  of  the 
malleus.  It  is  usualh'  wiser  in.  these  cases  to  divide  the  upper 
segment  first,  the  knife  being  carried  into  the  perforation  in 
terminating  the  posterior  and  anterior  incisions. 

It  may  seem  hazardous  to  subject  the  stapes  to  the  possi- 
bilities of  violence  attendant  upon  removal  of  the  malleus  be- 
fore the  incudo-stapedial  articulation  has  been  divided.  A 
moment's  reflection  will  convince  one,  however,  that  the 
presence  of  firm  connective  tissue  which  renders  the  proce- 
dure necessary  also  fixes  the  stapes  so  firmly  that  intelligent 
manipulation  can  scarcely  displace  it,  while  the  danger  of  in- 


OBSTACLES   TO    THE    REMOVAL    OF    THE    INCUS.       503 

flicting  such  an  injury  is  much  greater  if  an  attempt  is  made 
to  divide  the  articulation  with  the  field  of  operation  paitially 
obscured  by  blood.  Again,  it  frequently  happens  that  the 
long  process  of  the  incus  has  become  necrotic  and  the  articu- 
lation has  been  destroyed,  so  that  no  connection  between  the 
two  ossicles  exists. 

After  the  malleus  has  been  removed,  the  stapedius  muscle 
and  incudo-stapedial  articulation  should  be  found  and  divided, 
unless  this  step  has  already  been  performed,  after  which 
search  is  made  for  the  incus  in  the  manner  already  fully  de- 
scribed. It  should  be  remembered  that  as  caries  more  fre- 
quently attacks  the  incus  than  any  other  ossicle,  it  may  be 
partialh'  or  completely  destroyed.  In  the  former  case  its  re- 
moval is  often  difficult,  while  it  is  important  to  determine  with 
certainty  the  latter  condition,  to  avoid  a  proKir.ged  search  if 
it  is  absent.  It  should  also  be  borne  in  mind  that  the  i)atho- 
logical  process  may  have  resulted  in  a  b(inv  union  between 
the  incus  and  malleus,  and  that  both  ossicles  may  be  extracted 
together.  In  case  both  ossicles  were  intact,  the  operator  could 
not  overlook  such  an  occurrence  ;  but  when  one  or  both  have 
been  partially  destroyed,  careful  inspection  of  the  j)orti()ns  re- 
moved may  be  necessary,  to  determine  the  simultaneous  re- 
moval of  the  malleus  and  incus.  The  operator  should  then, 
upon  extracting  what  he  supposes  to  be  the  malleus,  carefully 
examine  it,  in  order  to  assure  himself  that  the  body  of  the  incus 
is  not  attached  thereto.  If  nothing  but  the  malleus  is  found, 
the  field  of  operation  should  be  dried  and  inspected  carefully. 
If  no  portion  of  the  incus  is  seen,  special  attention  should 
next  be  given  to  the  postero-superior  segment  of  the  field.  It 
sometimes  happens  that  the  incision  has  not  been  close  to  the 
tympanic  ring  in  this  region,  a  circumstance  not  easily  recog- 
nized unless  the  parts  are  touched  with  the  probe,  when  it  will 
be  found  that  a  small  curtain,  or  flap,  of  tissue  remains  undi- 
vided. The  destruction  of  a  small  part  of  the  ring  at  this  p(jint, 
as  the  result  of  caries,  also  gives  rise  to  a  similar  appearance. 
It  quite  frequently  happens  that  the  incus  is  adherent  to  this 
flap,  or  completely  concealed  bv  it.  Division  of  the  soft  parts 
close  to  the  bony  margin  will,  in  such  a  case,  bring  the  incus 
into  view.  If  not  found  in  this  situation,  the  ossicle  must  be 
searched  for  with  the  incus  hook,  in  the  manner  already  de- 
scribed while  considering  the  operation  in  cases  with  an 
intact  membrana  tympani.     If  all  of  these  manipulations  fail 


504 


MIDDLE-EAR   OPERATIONS. 


to  bring-  the  incus  into  view,  or  if  it  has  not  been  felt,  and  the 
incus  hook  can  be  carried  freely  from  behind-forward,  through 
the  vault  of  the  tympanum,  the  operator  may  decide  that  the 
ossicle  has  been  destroyed  by  caries,  or  that  it  has  suffered 
partial  destruction,  and  the  remaining  portion  has  become 
amalgamated  with  the  tympanic  roof.  If,  however,  it  has 
been  seen  or  felt  at  any  time,  its  subsequent  loss  will  mean 
dislocation  into  the  mastoid  antrum. 

The  management  of  the  stapes  and  the  region  of  the  round 
window  is  conducted  in  the  manner  already  described. 

Any  parts  of  the  membrana  tympani  which  may  remain  in 
the  lower  portion  of  the  fundus  are  to  be  removed  with  the 
knife,  curette,  and  forceps  if  they  are  the  seat  of  a  h3'pertrophic 
process,  as  evidenced  by  considerable  thickening  and  increased 
vascularity,  for  they  may  conceal  areas  of  bony  necrosis.  If, 
however,  the  appearance  of  the  lower  portion  of  the  mem- 
brane is  healthy,  we  may  feel  certain  that  the  bony  structures 
are  unaffected,  and  that  there  is  no  indication  for  the  removal 
of  the  lower  portion  of  the  membrane — in  fact,  its  presence 
will  hasten  cicatrization. 

After  drying  the  tympanum  thoroughly,  we  should  next 
search  for  softened  bone,  both  by  inspection  and  with  the 
probe.  Inspection  will  often  reveal  here  and  there  unhealthy 
granulation  tissue  indicative  of  the  presence  of  dead  bone. 
The  probe  should  be  made  to  traverse  carefully  the  entire 
inner  wall  of  the  tympanum,  and  should  also  be  bent  at  a 
right  angle  at  the  tip,  to  enable  the  surgeon  thoroughly  to 
explore  the  tympanic  vault.  The  curette  should  then  be 
freely  used,  and  all  granulation  tissue  and  softened  bone 
should  be  removed.  For  the  atrium  the  straight  curette 
(Fig.  123  a)  will  be  found  serviceable,  but  for  the  vault  the 
sharp  spoons,  bent  at  a  right  angle  (Fig.  123  //,  z),  must  be  called 
into  requisition.  This  procedure  of  thoroughly  removing  ex- 
uberant granulations  and  curetting  the  walls  of  the  entire  cav- 
ity is  of  the  greatest  importance,  and  should  be  conducted 
with  special  care,  as  the  ultimate  success  of  the  operation 
often  depends  quite  as  much  upon  this  step  as  upon  the  re- 
moval of  the  ossicles.  An  area  of  softened  bone  in  the  vault 
of  the  tympanum  will  keep  up  the  discharge  for  a  long  time, 
and  render  the  result  of  the  operation  far  from  satisfactory. 
Hence  quite  as  much  attention  should  be  given  to  this  proce- 
dure as  to  the  removal  of  the  ossicula.     After  the  bon}'  walls 


TREATMENT   AFTER   OPERATION.  505 

of  the  tvmpaniim  have  been  thoroughly  curetted,  the  margins 
of  the  tympanic  ring  should  receive  attention.  It  frequently 
happens,  when  long-continued  suppuration  has  existed,  that 
the  margin  of  the  ring  becomes  involved.  This  is  particularly 
true  of  the  superior  and  postero-superior  margin,  on  account 
of  its  intimate  relation  to  the  ossicula,  and  because  it  forms  a 
portion  of  the  floor  of  the  vault  of  the  tympanum.  Any 
roughness  or  softening  in  this  region  should  be  dealt  with 
radically.  All  diseased  areas  should  be  removed  with  the 
curette,  and  a  portion  of  the  ring  may  be  excised  with  tiie 
cutting  forceps  if  necessary. 

After  all  these  steps  have  been  carried  out,  the  treatment 
of  the  case  for  the  first  twenty-four  hours  will  not  differ  from 
the  after-treatment  of  cases  in  which  the  mcmbrana  tvmpani 
was  originally  intact.  The  treatment  subsequent  to  the  first 
twenty-four  hours,  however,  must  vary  with  each  individual 
case.  While  the  discharge  continues  profuse,  the  car  must  be 
cleansed  bv  the  patient  with  the  syringe  and  a  mild  antiseptic 
solution  twice  daily,  or  more  frequently  if  this  is  necessary  to 
keep  the  parts  clean.  At  the  end  of  a  week,  if  there  is  con- 
siderable discharge,  I  recommend  the  instillation  of  the  solu- 
tion of  boric  acid  in  alcohol  twice  daily  after  thorough  cleans- 
ing. Any  granulation  tissue  must  be  destroyed,  as  it  appears, 
by  means  of  chromic  acid,  silver  nitrate,  the  actual  cautery, 
or  any  other  destructive  agent.  If  it  is  found  that  all  carious 
bone  has  not  been  remove^,  lactic  acid,  applied  to  the  affected 
areas  by  means  of  a  cotton-tipped  probe,  is  frequently  suffi- 
cient to  determine  the  formation  of  healthy  granulation  tissue 
and  effect  complete  cicatrization.  The  concentrated  acid 
should  be  used,  and  should  be  thoroughly  rubbed  into  the 
tissues.  As  the  discharge  becomes  almost  7iil  we  may  dis- 
pense with  the  syringe,  and  the  patient  may  be  allowed  to 
cleanse  the  ear  by  means  of  pledgets  of  cotton  wound  upon 
any  convenient  probe,  while  the  surgeon  may  once  or  twice 
weekly  insufflate  a  small  quantity  of  boric  acid,  dermatol,  or 
other  mild  antiseptic  or  stimulating  powder,  until  all  dis- 
charge ceases.  It  has  been  mv  good  fortune  in  all  such  cases 
either  to  stop  the  discharge  completely  or  to  diminish  it  so 
much  that  it  has  ceased  to  be  a  source  of  annoyance.  The 
length  of  titne  which  must  elapse  after  the  operation  before 
complete  cessation  of  the  discharge  must  vary  with  each 
case,  depending  upon  the  extent  of  the  original  involvement. 

34 


5o6 


MIDDLE-EAR    OPERATIONS. 


From  six  to  eight  weeks  is  the  average  time.  In  some  cases 
cicatrization  may  be  perfect  at  the  end  of  two  or  three  weeks, 
while  in  others  the  same  number  of  months  must  elapse. 

The  technique  given  varies  in  some  particulars  from  that 
advocated  by  other  operators.  In  the  division  of  the  incudo- 
stapedial  articulation  the  ordinary  direction  is  to  enter  the 
knife  behind  the  long  arm  of  the  incus  and  divide  the  articu- 
lation by  cutting  downward  and  forward.  Those  who  advo- 
cate this  plan  of  procedure  say  that  the  pressure  of  the  instru- 
ment is  then  opposed  by  the  action  of  the  stapedius  muscle, 
and  danger  of  injury  to  the  stapes  is  avoided,  while  at  the 
same  time  the  resistance  of  the  stapedius  renders  the  division 
more  easy.  My  own  preference  is  to  sever  completely  the 
stapedius  tendon  before  attempting  to  disarticulate,  as  by  this 
means  the  articulation  is  brought  more  perfectly  into  view 
through  the  action  of  the  tensor  tvmpani  and  tense  ligament- 
ous bands  located  anteriorly.  If  the  stapedius  muscle  is  not 
completely  divided  as  the  initial  step,  the  stapes,  after  disarti- 
culation, is  frequently  pulled  out  of  sight  behind  the  margin  of 
the  tympanic  ring.  After  division  of  the  stapedius,  disarticu- 
lation by  the  method  usually  recommended  may  dislocate  the 
stapes,  although  this  is  not  likely  to  occur.  It  is  often  dif^- 
cult,  however,  to  insert  the  knife  between  the  tympanic  ring 
and  the  long  arm  of  the  incus,  and  for  this  reason  I  prefer  the 
method  given  in  my  description  of  the  technique  of  the  pro- 
cedure— that  is,  to  pass  the  angular  knife  in  front  of  the  long 
arm  of  the  incus  and  open  the  articulation  by  cutting  down- 
ward and  backward  against  the  pull  of  the  tensor  tympani,  or 
to  open  the  joint  at  its  lower  aspect,  and  then  to  sweep  the 
knife  through  it  by  carrying  it  backward  and  forward.  By 
either  of  these  methods  the  joint  is  more  easily  opened  than 
when  an  attempt  is  made  to  carry  the  angular  blade  behind 
the  long  process  of  the  incus,  which  frequently  lies  so  close  to 
the  tympanic  margin  that  considerable  violence  must  be  used 
in  introducing  the  knife. 

In  removing  the  incus  Kretschmann,*  who  was  the  first  to 
formulate  the  procedure  for  removing  this  ossicle,  made  use 
of  a  hook  which,  in  addition  to  the  curve  shown  in  Fig.  121 J k, 
was  bent  outward  at  the  distal  extremity  so  that  when  the  in- 
strument was  in  position  the  tip  rested  upon  that  small  shelf- 

*  Arch,  fiir  Ohrenheilk.,  vol.  xxv,  p.  165. 


CARIES    OF    THE    INCUS.  507 

like  structure  of  the  superior  wall  ot  the  canal  which  affords 
lodgment  for  the  incus.  He  introduced  the  instrument  with 
the  concavity  directed  backward,  and  brought  the  incus  into 
view  by  rotation  backward  and  traction  downward.  While 
this  manipulation  is  no  doubt  of  great  value  in  certain  cases, 
the  backward  rotation  seems  more  likely  to  carry  the  ossi- 
cle far  out  of  reach  toward  the  mastoid  antrum  in  case  it  is 
not  secured  at  once,  and  the  manipulation  of  attempting  to 
bring  the  long  process  into  view  by  passing  a  hook  behind  it 
and  rotating  forward  has  in  my  hands  proved  very  satisfac- 
tory, while  it  certainly  lessens  the  danger  of  displacing  the 
ossicle  far  backward. 

The  teaching  that  it  is  not  advisable  to  make  a  prolonged 
search  for  the  incus  seems  to  me  unwise.  In  nonsuppurative 
cases  careful  manipulation  will  render  failure  to  secure  it  ex- 
ceedingly rare.  If  it  has  not  been  displaced  it  must  occupy 
its  original  position,  and  failure  to  bring  the  long  process  into 
the  held  of  vision  will  render  it  imj)ossible  for  the  operator  to 
be  certain  of  a  complete  division  of  the  incudo-stapedial  articu- 
lation ;  or  if  the  head  of  the  stapes  is  seen  lying  free  in  the 
held,  it  is  certain  that  the  incus  has  been  displaced  and,  by 
acting  as  a  foreign  bodv,  may  give  rise  to  trt)uble  if  allowed 
to  remain.  If  the  long  process  is  in  view  there  is  no  difhculty 
in  removing  the  ossicle. 

In  purulent  cases  it  is  still  more  important  that  the  ossicle 
should  be  removed.  Ludewig  ■■■  found  the  incus  carious  in 
eighty-five  per  cent  of  the  cases  u\nm  whic  h  ^^_^ 

he  operated.     In  twenty-nine  cases  of  puru-       '^^        ^^^ 
lent  otitis  operated  upon  by  the  auth(H-.+  the     '' '|;,,/uf  "Long  pro-^ 
ossicle  was  carious  in  nineteen,  while  in  eight       cess     destroyed; 

•     111  1^11^  ]       13       1  I  articular     .surface 

It  had  been  completely  destroyed.  Prolonged  eroded.  (Auiho.'s 
manipulation  in  searching  for  the  ossicle  has  specimen,  natural 
not,  in  my  hands,  in  any  way  added  to  the  re- 
action following  the  procedure,  nor  has  it  interfered  with  the 
results.  I  should  therefore  earnestly  advise  prolonging  the 
operation  for  the  purpose  of  securing  the  incus  rather  than 
performing  a  rapid  operation  and  failing  in  its  removal. 

Among  the  complications  which  may  interfere  with  the 
operation,  haemorrhage  is  the  one  upon  which  special  empha- 


*  Arch,  fiir  Ohrenheilk.,  vol.  xxix,  p.  241  ;  vol.  xxx,  p.  263. 

f  Supplement  to  the  Reference  Handbook  of  Medical  Sciences,  New  York,  1893. 


5o8 


MIDDLE-EAR    OPERATIONS. 


sis  is  laid.  Since  I  have  operated  with  the  patient  in  the  semi- 
recumbent  position  rather  than  with  the  head  low,  annoying 
hcemorrhage  has  been  the  exception  rather  than  the  rule.  If 
it  is  sufficient  in  amount  to  interfere  with  the  manipulation, 
it  can  always  be  checked  by  tamponing  the  canal  firmly  with 
cotton  pledgets.  It  is  important  in  executing  this  manoeuvre 
that  the  first  pledget  of  cotton  should  be  carried  well  into  the 
tympanic  cavity,  and  also  that  the  individual  pledgets  should 
not  be  too  large,  as  the  force  necessary  for  the  removal  of 
a  large  tampon  is  likely  to  lead  to  a  recurrence  of  the  haemor- 
rhage. This  objection  is  overcome  if  a  number  of  small  plugs 
are  used  instead  of  a  few  larger  ones.  It  may  be  necessary 
to  repeat  the  tamponing  several  times,  but  it  will  certainly 
effect  its  purpose  if  a  little  patience  is  exercised.  A  ten-per- 
cent solution  of  cocaine  is  said  to  be  useful  in  checking  a 
slight  oozing,  but  I  have  never  had  occasion  to  use  it. 
Schmiegelow  *  has  reported  one  case  in  which  the  haemor- 
rhage was  so  severe  that  he  was  obliged  to  discontinue  an 
attempt  to  excise  the  malleus. 

My  own  experience  with  intratvmjianic  operations,  more 
especially  the  particular  class  now  under  discussion,  has  led 
me  to  consider  them  remarkably  free  from  risk.  It  is  possi- 
ble, however,  for  unpleasant  sequela?  to  follow  such  proce- 
dures. Among  these  the  most  important  are  injury  to  the  facial 
nerve,  deafness  from  accidental  impaction  of  the  stapes  into 
the  oval  window,  injury  to  the  labyrinth  from  accidental  or 
intentional  removal  of  the  stapes,  either  by  direct  trauma- 
tism or  by  infection,  etc.,  and  inflammation  of  the  mastoid 
process. 

The  facial  nerve  is  occasionally  injured  by  the  incus  hook. 
The  cause  of  this  accident  is  to  be  found  either  in  a  congenital 
defect  in  the  Fallopian  canal  or  in  the  partial  or  complete  de- 
struction of  its  walls  as  the  result  of  disease.  With  the  exer- 
cise of  a  little  care  in  manipulating  the  incus  hook,  bearing  in 
mind  that  great  force  is  not  necessar}-  to  displace  the  ossicle, 
the  accident  can  usuall}^  be  avoided.  If  the  facial  nerve  is 
touched  by  the  instrument  the  twitching  of  the  face  immedi- 
ately warns  the  operator  of  wiiat  has  occurred,  and  subse- 
quent caution  will  prevent  serious  injury.  In  one  of  my  own 
cases  twitching  of  the  face  was  noticed  while  attempting  to 


Hospitals  Tidende,  3,  K.  V.,  Nos.  22-26. 


STACKK'S    OPERATION. 


509 


locate  the  incus,  and  upon  recovery  from  anaesthesia  there  was 
marked  paresis  of  the  corresponding  side  of  the  face  ;  the  fa- 
cial nerve  had  been  slightlv  involved  before  the  operation,  but 
after  this  the  signs  were  much  more  pronounced.  The  paraly- 
sis disappeared  under  the  use  of  the  faradic  current.  Facial 
paralysis  consecutive  to  a  similar  operation  occurred  also  in  a 
case  reported  by  Ludewig.* 

In  view  of  the  fact  that  all  portions  of  the  tvmjianic  cavitv 
are  not  accessible  through  the  canal,  and  in  order  that  the  pro- 
cedure may  be  more  directly  under  the  eye  of  the  operator, 
Stacke  f  prefers  to  expose  the  parts  by  external  incision.  His 
method  is  as  follows  :  An  incision  is  made  down  to  the  bone 
just  behind  the  attachment  of  the  auricle,  and,  following  this 
in  direction,  is  continued  from  the  tip  of  the  mastoid  process 
to  a  point  just  above  the  tragus.  With  a  small  elevator  the 
cartilaginous  meatus  and  as  much  as  possible  of  the  perios- 
teum of  the  osseous  canal  are  separated  from  the  bony  parts. 
In  this  manner  the  superior,  posterior,  and  inferior  as{)ects  of 
the  margin  of  the  bonv  lueatus  are  exposed.  The  soft  parts 
are  now  divided  transverselv  downward  and  forward  as 
deeply  in  the  canal  as  possible,  and  bv  traction  upon  the  auri- 
cle the  funnel-like  mass  is  pulled  out  of  the  bony  meatus  <  Fig. 
150).  The  periosteum  of  the  anterior  wall  is  next  divided, 
when  the  entire  cartilaginous  meatus  and  a  part  of  the  thin 
cutaneous  lining  of  the  osseous  canal  may  by  traction  for- 
ward be  so  displaced  as  to  leave  the  margin  of  the  bony 
meatus  entirelv  free.  The  tympanic  structures  may  then  be 
seen  by  direct  light  and  all  affected  parts  removed.  By 
means  of  the  gouge  the  superior  and  posterior  margins  of  the 
inner  extremity  of  the  bony  meatus  may  now  be  removed, 
and  the  stapes  being  protected  by  a  proper  instrument,  the 
curette  may  be  freely  used  in  the  vault  of  the  tympanum, 
the  manipulations  being  under  ocular  inspection.  In  this 
manner  the  entire  cavity  may  be  cleared  completely  of  ne- 
crotic tissue  and  the  mastoid  antrum  even  may  be  exposed. 
In  case  there  is  evidence  of  serious  mastoid  involvement  the 
original  incision  is  made  a  little  farther  back  than  directed  and 
the  antrum  entered  in  the  ordinary  wa}-,  after  which  the  tym- 
panic cavity  is  exposed  and  treated  in  the  manner  described, 

*  Arch,  fiar  Ohrenheilk.,  vol.  xxix,  p.  259. 
f  Ibid.,  vol.  xxxi,  p.  201. 


CIO  MIDDLE-EAR    OPERATIONS. 

and  finally  the  canal  and  the  artificial  opening-  into  the  antrum 
are  thrown  into  one.  In  this  way  the  middle  ear,  mastoid 
cells  and  canal  are  converted  into  a  single  cavity,  all  parts  of 
which  are  easily  accessible  through  the  external  meatus. 

After  the  operation  the  cartilaginous  canal  is  replaced  and 
a  drainage-tube  is  passed  into  the  bony  meatus,  completely  fill- 
ing its  lumen,  thus  preventing  displacement.  The  external 
incision  is  sutured,  all  drainage  being  through  the  meatus.  In 
cases  where  the  mastoid  antrum  has  been  freely  exposed  it  is 
usual  to  incise  the  soft  parts  of  the  canal  longitudinally  along 
the  posterior  aspect  and  press  the  flaps  thus  formed  backward 
into  the  cavity,  holding  them  in  position  with  tampons  of  iodo- 
form gauze.  In  this  manner  a  cutaneous  lining  for  the  mas- 
toid antrum  is  secured.  The  same  result  is  attained  by  cut- 
ting a  quadrilateral  Hap  from  the  cutaneous  canal  and  carrying 
it  into  the  antrum. 

Stapedectomy. — (a)  Ulioi  the  jucuibrana  fyi/ipaui  is  intact. 
The  incudo-stapedial  articulation  is  exposed  cither  by  a  curved 
incision  in  the  postero-superior  quadrant  close  to  the  attach- 
ment of  the  membrane  to  the  tympanic  ring,  or  by  a  triangu- 
lar incision  in  this  situation,  or  by  the  incision  already  de- 
scribed in  the  operation  of  exploratory  myringotomv.  After 
the  incudo-stapedial  articulation  is  brought  into  view  the  sta- 
pedius muscle  should  be  completelv  divided  ;  the  incudo-sta- 
pedial articulation  is  then  severed  and  the  long  arm  of  the 
incus  pushed  forward  so  as  not  to  interfere  with  the  subse- 
quent steps.  If  the  presence  of  the  incus  still  interferes  with 
the  separation  of  the  stapes  the  long  process  may  be  seized 
with  the  forceps  and  the  ossicle  removed.  The  stapes  is  then 
freed,  b)^  means  of  the  sharp  straight  knife,  from  adhesions 
binding  it  to  the  oval  niche,  and  is  removed  by  gentle  traction 
with  the  forceps  or  by  a  hook  passed  between  the  crura.  It  is 
important  to  sever  the  stapedius  muscle  completely  before  dis- 
articulation, as  otherwise,  after  separation  from  the  incus,  the 
stapes  may  be  pulled  out  of  view.  If  the  foot  plate  is  found 
anchylosed  this  condition  may  be  treated  in  the  manner  al- 
ready suggested,  although  in  such  a  case,  as  the  parts  would 
be  subjected  to  more  violence,  it  is  probable  that  removal  of 
the  malleus,  incus,  and  membrana  tympani  would  diminish 
the  chances  of  reaction  after  the  operation. 

After  the  first  incision  through  the  membrana  tvmpani. 
the  direct  application  of  the  cocaine  solution  to  the  middle 


REMOVAL    OF   THE    STAPES. 


511 


ear  by  means  of  a  cotton-tipped  probe  renders  the  subse- 
quent steps  painless.  In  three  cases  of  this  kind  I  have  been 
able  to  clear  the  oval  niche  in  the  above  manner,  no  pain 
being  experienced  after  the  first  incision  through  the  mem- 
brana.  If  a  very  sharp  knife  is  used  this  is  never  severe. 
After  this  no  pain  need  be  felt  if  cocaine  is  carefully  applied. 
My  results  have  been  fairly  satisfactory  ;  but  I  am  inclined  at 
present  to  confine  the  procedure  to  cases  where  the  condi- 
tion has  resulted  from  a  suppurative  inflammation,  and  in  non- 
suppurative cases  to  mobilize  the  stapes  instead  of  removing 
it.  In  these  cases,  if  mobilization  improves  the  hearing,  I 
also  prefer  to  remove  the  malleus  and  incus,  thus  leaving  the 
stapes  accessible  in  case  a  second  mobilization  becomes  ne- 
cessary. 

After  removal  of  the  stapes  the  flap  may  be  replaced  and 
held  in  position  by  a  paper  dressing.  The  meatus  is  occluded 
by  a  plug  of  antiseptic  cotton,  which  is  left  in  position  for 
several  days  unless  inflammatory  svmyjtoms  supervene.  The 
wound  usually  heals  in  a  few  days,  and  in  no  case  has  the  re- 
action been  severe. 

(b)  ]\7un  the  vicnibrnnc  is  partially  destroyed  the  stapes  or 
the  incudo-stapedial  articulation  may  be  ahead y  in  view  ;  but 
if  neither  is  visible,  the  appropriate  incision  for  the  expo- 
sure of  these  parts  will  var}-  in  each  case,  after  which  the 
technique  previously  given  is  to  be  carried  out.  In  two  cases 
operated  upon  under  local  anaesthesia,  the  stapes  being  clearly 
in  view,  extraction  was  easily  accomplished  and  the  results 
were  flattering,  in  one  instance  the  hearing  for  a  low  whisper 
increasing  from  seven  to  thirty  feet.  Here  the  entire  stapes 
was  removed  intact.  In  the  second  case  only  a  portion  of 
the  ossicle  was  secured  and  removed,  yet  the  improvement 
was  considerable.  It  is  well  to  bear  in  mind  that  even  slight 
heemorrhage  will  render  the  removal  of  the  stapes  difficult; 
and  when  this  region  is  covered  by  dense  structures,  which 
bleed  freely  when  incised,  it  may  be  necessary  to  remove  the 
nralleus  and  incus  and  remains  of  the  membrane  to  secure  a 
suitable  field  for  the  performance  of  stapedectomy. 

The  after-treatment  may  be  the  same  as  in  the  preceding 
class  of  cases.  It  is  well,  however,  to  inspect  the  ear  at  the 
end  of  twenty-four  hours,  and,  if  signs  of  inflammation  are 
present,  to  cleanse  it  frequently  with  a  mild  antiseptic  solu- 
tion.    If,  however,  the  parts  are  perfectly  dry,  thc}^  should 


CI2  MIDDLE-EAR   OPERATIONS. 

not  be  disturbed,  for  fear  of  interfering  with  the  healing- 
process. 

From  personal  experience,  the  author  believes  that  at  the 
present  time  a  lesion  of  the  conducting  mechanism  resulting 
from  a  nonsuppurative  inflammation  which  demands  opera- 
tive interference  will  be  more  satisfactorily  combated  by  the 
removal  of  the  membrana  tympani,  malleus,  and  incus,  and  mo- 
bilization of  the  stapes,  than  by  other  operative  measures.  In 
residual  purulent  cases  mobilization  of  the  stapes  will  usually 
yield  results  equally  as  good  as  those  obtained  by  stapedec- 
tomy. The  advantage  of  removing  the  two  larger  ossicles  in 
both  classes  of  cases  lies  in  the  fact  that  the  stapes  is  thus  left 
exposed,  and  can  be  repeatedly  mobilized  if  necessary.  When 
the  ossicle  is  mobilized  or  removed,  and  the  flap  of  drum  mem- 
brane is  allowed  to  resume  its  former  position,  the  beneficial 
results  are  often  but  temporary,  and  disappear  when  the 
opening  in  the  membrana  closes. 

When  operations  are  performed  for  improvement  of  func- 
tion they  may  always  be  conducted  under  local  antcsthesia, 
and  the  improvement  or  failure  to  improve  may  be  noted  at 
each  successive  step.  The  operation  can  therefore  be  discon- 
tinued at  any  stage,  if  the  operator  judges  that  he  is  not  war- 
ranted in  proceeding. 

The  results  of  my  operations  were  reported  *  a  few 
months  since,  and  the  compilation  which  follows  includes  a 
few  additional  cases. 

Of  cases  where  the  membrana  tympani  was  intact,  includ- 
ing one  or  two  instances  where  there  had  been  a  suppurative 
process  in  childhood,  with  complete  closure  of  the  perfora- 
tion, twenty-one  have  been  subjected  to  operation  under  co- 
caine anaesthesia.  Of  these,  there  was  much  improvement  in 
thirteen  cases,  with  a  slight  relapse  in  one  case ;  there  was  a 
moderate  amount  of  improvement  in  seven,  with  a  relapse  in 
one  instance  ;  and  in  one  case — a  female  of  neurotic  tempera- 
ment— the  improvement  was  but  slight. 

In  thirteen  cases  of  this  character  operated  upon  under 
ether,  two  were  greatly  improved,  five  much  improved,  five 
slightly  improved,  and  in  the  remaining  case  the  condition 
remained  the  same  as  before  operation. 

In  eleven  cases  the  condition  was  due  to  a  previous  purulent 

*  Transactions  of  the  American  Otological  Society,  1894. 


STATISTICS    OF    AUTHOR'S   OPERATIONS.  513 

inflammation,  which  had  resulted  either  in  a  slight  or  extensive 
destruction  of  the  membrana  tympani,  the  perforation,  persist- 
ing. The  operative  procedures  were  confined  to  freeing  the 
stapes  and  mobilizing  it,  as  described  in  the  preceding  pages, 
without  resort  to  general  anaesthesia.  Of  these,  there  was 
great  improvement  in  one,  the  whispering  distance  increasing 
from  twelve  inches  before  to  fifteen  feet  after  operation,  and 
the  degree  of  improvement  being  maintained  at  the  time  of  the 
last  examination,  which  was  about  six  weeks  after  operation. 
In  ten  there  was  decided  improvement,  although  not  as  great 
as  in  the  case  just  mentioned.  Of  the  eleven  cases,  disagree- 
able symptoms  followed  the  operation  in  but  one  instance. 

In  ten  cases  there  was  a  purulent  otitis,  in  which  the  opera- 
tion was  performed  both  for  the  relief  of  the  otorrhoea  and  at 
the  same  time  to  improve  the  hearing.  Of  these,  there  was 
great  improvement  in  five,  moderate  improvement  in  three, 
while  in  two  the  lunction  of  the  organ  remained  the  same  as 
before  operation. 

In  ten  cases  the  membrana  was  intact  and  the  stapes  was 
removed,  or  the  crura  fractured  in  the  attempt  at  removal, 
the  operation  being  done  with  cocaine.  In  most  instances 
removal  of  the  incus  was  necessary  in  order  to  gain  access  to 
the  stapes.  Of  the  ten  cases,  three  were  improved,  two  were 
much  improved,  one  slightly  improved,  two  unimproved,  and 
two  were  made  worse.  In  one  case,  where  much  improve- 
ment followed  the  operation,  a  relapse  took  place  at  a  later 
period,  although  the  hearing  still  remained  better  than  before 
the  operation. 

In  quite  a  number  of  these  cases  of  stapedectomy  it  was 
found  that  the  improvement  became  much  less  after  the  per- 
foration in  the  membrana  tympani  closed,  and  in  these  in- 
stances the  malleus  and  membrana  tympani  were  removed  at 
a  later  period,  in  order  to  secure  a  permanent  opening  into 
the  tvmpanic  cavity.  This  procedure  was  followed  by  im- 
provement in  all  the  cases.  In  one  instance  synechiotomy 
was  practiced  for  the  improvement  of  hearing  before  the 
purulent  discharge  had  ceased  entirely,  this  being  so  moder- 
ate in  amount  as  scarcely  to  warrant  general  anaesthesia  and 
the  removal  of  the  entire  ossicular  chain.  Slight  improve- 
ment followed  the  procedure  in  this  instance. 

It  will  be  seen  from  these  statistics  that  the  greatest  im- 
provement  has  followed   those  operations   performed  under 


c,4  MIDDLE-EAR   OPERATIONS. 

cocaine  anaesthesia,  and  where  the  design  has  been  to  secure 
a  permanent  opening  into  the  tympanum.  This  seems  to  be 
the  most  rational  procedure  in  all  cases  where  the  membrana 
tympani  is  intact ;  and  since  it  can  be  done  without  general 
anaesthesia,  we  are  certainly  warranted  in  recommending  at 
least  an  exploratory  tympanotomy  in  all  cases  where  the  hear- 
incr  has  failed  to  improve  under  less  radical  measures.  In  no 
given  case  can  we  state  the  amount  of  improvement  which  we 
should  expect,  and  it  is  always  our  duty  to  inform  the  patient 
of  the  experimental  character  of  the  measure.  From  the  fact, 
however,  that  the  procedure  is  followed  by  no  discomfort; 
that  it  can  be  performed  without  pain,  and  that,  humanly 
speaking,  it  will  not  injure  the  organ,  we  certainly  fail  to  ful- 
fill our  entire  duty  to  the  patients  if  the  subject  is  not  pre- 
sented to  them  fairly. 


PLATE   VII. 


The  Mastoid  Operation. 


CIIAI'TF.R    XXVIII. 
thp:  mastoid  operation. 

The  instruments  retjuircd  arc  a  mcdiuin-sizcd  scalpel  (Fi^:^. 
141),  thumb  forceps  (Fig.  142),  scissors  (Fig.  143),  retractors, 
either  sharp  or  blunt  (F"ig.  144).  a  periosteum  elevator  (Figs. 
145,  146),  a  rongeur  forceps  (Fig.  147),  sharp  spoons  (Figs. 
123,  a,  and  148),  a  silver  probe,  a  wooden  or  rawhide  mallet, 
and  chisels  or  gouges  of  various  sizes  (Fig.  149).  It  is  also 
well  to  have  a  small  trephine  at  hand.  The  usual  sujiply  of 
artery  clamps  (not  less  than  six),  needles,  and  silk  and  catgut 
sutures  will  naturallv  form  a  part  of  the  armamentarium. 

The  ear  should  be  first  thoroughlv  cleansed  by  syringing 
with  i-to-i.ooo  bichloride  solution,  or  with  a  dilute  (i  to  10) 
solutit)n  of  peroxide  of   hydrogen,  after  which  the  meatus  is 


Fig.  141. — Scalpel  for  incising  the  soft  p  I  he  handle 

is  of  melal,  and  the  extremity  is  u>clu;  m  rlc.uiiig  ihc  iiciiusUiiin. 

thoroughly  tamponed  with  iodoform  gauze.  The  scalp  should 
be  shaved  over  an  area  extending  in  every  direction  for  a  dis- 
tance of  three  inches  from  the  meatus,  and  if  the  patient  has  a 
beard  it  should  also  be  rem(jved.  The  skin  is  then  scrubbed, 
first  with  soap  and  water  and  then  with  ether,  and  finally 
with  a  solution  of  bichloride  of  mercury  (i  to  1,000),  or  a  two- 
and  a-haU-per-cent  solution  of  carbolic  acid.  A  wet  bichloride 
dressing  is  then  applied  over  the  entire  field  of  operation  and 
allowed  to  remain  until  the  patient  is  anaesthetized.  When 
possible,  this  preparation  of  the  field  should  be  made  at  least 
four  or  five  hours  before  the  time  of  operation. 

After  the  induction  of  anaesthesia  the  antiseptic  dressing 
is  removed,  the  tampon  within  the  canal  is  changed,  and  the 
integument  washed  as^ain  with  ether,  and  irrig-ated  subse- 
quently  with  a  bichloride  solution  (i  to  2,000).  The  parts 
immediately   surrounding  the   field   should  be  covered  with 


i6 


THE    MASTOID    OPERATION. 


towels  moistened  in  i-to-i,ooo  bichloride  solution.  All  instru- 
ments are  to  be  sterilized  by  boiling,  and  the  hands  of  the 
operator  and  his  assistants  should  receive  the  ordinary  atten- 
tion demanded  in  all  surgical  operations. 

It  may  seem  unnecessary  to  take  all  these  precautions  in  a 
procedure  apparently  so  simple ;  but  when  we  remember 
that,  owing  to  an  anomalous  position  of  the  parts,  or  to  the 
destruction  resulting   from   the   inflammation,  we  may  either 


Fic.   142. — Thumb 
forceps. 


Fig.  143. — Blunt  scis- 
sors for  separating 
sterno-mastoid  mus- 
cle from  tip  of  mas- 
toid. 


Fig.  144. — Sharp 
retractor. 


enter  the  cranial  cavity  accidentally  or  feel 
compelled  to  do  so  as  a  matter  of  election, 
we  should  never  undertake  the  procedure 
without  being  thoroughly  prepared  to  extend 
our  operation  in  this  direction  if  necessary. 
The  primary  incision  begins  over  the  middle  Fig.  145.— Perios- 
of  the  mastoid  insertion  of  the  sterno-cleido-  '^""^  ^'^^^tor. 
mastoid  muscle,  about  half  an  inch  below  the  tip  of  the  mas- 
toid process,  and  is  carried  upward  and  forward  close  to 
the  line  of  insertion  of  the  auricle,  after  which  it  follows 
this  line  to  a  point  directly  above  the  meatus  (see  Plate 
VIIV     Particular  attention  should  be  given  to  the  location 


DIVISION    OF   SOP'T    PARTS. 


517 


Fig.   147. — Rongeur 
foiccps. 


of  this  incision,  as  ordinarily  the  line  of  section  lies  so  far  back 
that  when  the  flaps  are  retracted  the  posterior  and  superior 
walls  of  the  canal  are  not  freely  exposed.  In  addition  to  this, 
the  free  vascular  supply  of  the 
anterior  flap  causes  it  to  be- 
come oedematous  almost  im- 
mediately, thus  increasing  the 
difficulty  with  wiiich  it  is  drawn 
forward,  rendering  a  perfect 
exposure  of  the  parts  imjiossi- 
ble.  If  the  line  of  incision  is 
made  so  close  to  the  auricular 
insertion  as  to  admit  of  the  in- 
troduction of  a  line  of  sutures 
only,  the  field  of  operation  will 
be  much  better  exposed,  while 
subsequent  deformity  will  be 
prevented,  the  cicatrix  being- 
concealed  completely  by  the  Fig.  14(1.— li.ut- 
auricle,  which  resumes  an  abso-  l"u'mekvaio°rI 
lutcly  normal  position.  The 
soft  parts  should  be  divided  to  the  bone  throughout  the 
entire  extent  of  the  incision.  If  bleeding  is  free,  the  larger 
vessels  may  be  grasped  with  clamps,  although  it  is  better  or- 
dinarily to  delay  this  until  the  periosteum  has  been  elevated. 
This  constitutes  the  next  step  of  the  operation  :  The  entire 
anterior  flap  is  pushed  forward  by  means  of  an  elevator  car- 
ried beneath  the  periosteum,  raising  this  and  the  overlying 
muscular  structures  from   the  bone,  the  j)arts  being  pushed 

h'U',.   14S. —  Sliarp  spoon. 

forward  until  the  posterior  and  superior  margins  of  the  bony 
canal  are  plainly  in  view.  The  posterior  flaj)  is  elevated  in  a 
similar  manner.  All  bleeding  points  are  now  caught  by  means 
of  clamps.  The  auricle  is  held  forward  by  a  narrow  retractor 
inserted  into  the  meatus,  the  instrument  being  intrusted  to  the 
hands  of  the  assistant.  The  upper  part  of  the  incision  is  filled 
with  sponges,  in  order  that  all  oozing  may  be  controlled,  while 
the  operator  directs  his  attention  to  clearing  the  aponeurosis 
of  the  sterno-mastoid  muscle  from  the  tip  of  the  process. 


5i8 


THE    MASTOID   OPERATION. 


This  is  best  done  with  blunt  scissors  curved  on  the  flat, 
which  can  be  closely  applied  to  the  bony  surface  and  made 
to  divide  the  dense  fibrous  tissue  by  successive  short  cuts. 
Care  must  be  taken  to  hug  the  bone  closely,  otherwise  the 
large  vessels  of  the  neck  may  be  injured.  This  separation  of 
the  muscle  should  be  continued  until  the  finger  can  be  passed 
completely  around  the  tip  of  the  mastoid,  and  if  the  primary 
incision  has  not  been  made  low  enough  to  allow  this,  it  must 
be  extended.  The  packing  is  now  removed  from  the  upper 
part  of  the  wound  and  the  exposed  area  is  examined  for 
the  presence  of  any  sinus,  the  result  of  spontaneous  rup- 
ture. If  this  is  found,  it  is  enlarged  either  by  the  curette  or 
g(}uge,   the  surgeon  following   the   channel   which   has  been 

thus  established,  and 
which  will  be  found 
in  all  cases  to  com- 
municate either  di- 
rectly or  indirectly 
with  the  mastoid  an- 
trum. If  no  sinus 
is  present,  the  first 
step  in  every  case  is 
to  enter  the  antrum. 
We  remember  the 
location  of  this  to  be 
just  behind  the  pos- 
terior margin  of  the 
meatus  and  just  be- 
low its  superior  mar- 
gin.    Until  we  have 


-Schwartze's  mastoid  chisels.  ^^^""^^     entrance     tO 

this  cavity  our  open- 
ing through  the  cortex  should  never  extend  above  the  supe- 
rior wall  of  the  canal,  thus  avoiding  the  middle  cranial  fossa, 
while  we  should  keep  close  to  the  posterior  wall  on  account 
of  a  possible  malposition  of  the  lateral  sinus. 

The  cortex  is  best  removed  bv  means  of  the  chisel  (Fig. 
149)  and  mallet,  a  large  cutting  instrument  being  used  at 
first  and  changed  for  a  smaller  one  as  the  wound  is  deep- 
ened. The  chisel  is  applied  nearlv  parallel  to  the  surface  of 
the  skull,  and  made  to  cut  awav  the  bone  in  thin,  broad 
chips,  the   cutting  edge  being  directed   downward   and   for- 


REMOVAL   OF   SOFTENED   BONK. 


519 


ward.  In  this  way  we  form  a  bonv  funnel,  the  base  of  which 
may  be  broadened  posteriorly  and  below,  if  necessary,  but 
never  above.  The  apex  of  the  cone  should  always  lie  within 
the  triangle  which  marks  the  entrance  to  the  antrum.  Where 
the  pneumatic  spaces  are  superficial  they  may  be  opened 
with  the  first  blow  of  the  mallet,  after  which  it  is  wise  to 
lay  aside  the  chisel  and  continue  the  operation  by  means  of 
the  sharp  spoon  (Fig.  I4<S).  breaking  down  the  walls  of  tlie 
air  spaces  until  the  mastoid  antrum  is  entered.  This  never 
lies  less  than  half  an  inch  below  the  surface,  although  we 
may  encounter  large  pneumatic  spaces  more  superficially. 
We  recognize  that  the  antrum  is  entered  by  the  fact  that  a 
probe,  slightly  curved  at  the  tip,  after  entering  the  artificial 
opening,  passes  downward,  forward,  and  inward  for  a  dis- 
tance of  from  three  quarters  to  seven  eighths  of  an  inch,  at 
which  depth  it  enters  a  cavity  of  considerable  size  ;  in  other 
words,  it  has  passed  into  the  middle  ear.  We  persist  in  our 
efforts  at  entering  this  cavity,  although  pus  may  have  been 
evacuated  previously.  The  passage  between  the  antrum  and 
the  tympanum  should  next  be  curetted  freely  by  means  of  a 
delicate  sharp  spoon  (Fig.  123,  a).  This  portion  of  the  tract 
is  invariably  occluded  by  granulation  tissue,  while  its  bony 
walls  are  often  carious. 

The  next  step  is  to  thoroughly  obliterate  the  entire  pneu- 
matic structure  of  the  mastoid  process.  The  remaining  cortex 
is  removed  with  the  chisel,  curette,  or  rongeur,  as  may  be 
most  convenient.  The  large  cell  at  the  apex  must  be  j)articu- 
larly  investigated,  opened  freely,  and,  if  its  walls  are  carious, 
the  tip  of  the  process  should  be  removed  with  the  rongeur 
forceps.  The  operati(Mi  should  be  continued  until  sound 
bone  is  encountered  in  every  direction.  If  the  inner  table  is 
affected,  we  should  not  hesitate  to  remove  it,  as  an  exposure 
of  the  dura  under  proper  precautions  is  a  matter  of  no  imj^or- 
tance,  while  to  leave  carious  bone  in  contact  with  this,  is  a 
grave  error.  Exposure  of  the  lateral  sinus,  either  accident- 
ally or  intentionally,  in  no  way  complicates  the  operation.  If 
the  vessel  is  opened,  sharp  haemorrhage  results,  and  herein 
lies  the  advantage  of  extensively  removing  the  cortex.  If  the 
wounded  vessel  lies  at  the  bottom  of  a  deep,  narrow,  bony 
channel,  the  haemorrhage  may  be  controlled  ;  but  it  is  diffi- 
cult to  proceed  with  the  operation,  and  the  purpose  for  which 
it  was  instituted  will  therefore  not  be  carried  out.     With  a  free 


520 


THE    MASTOID    OPERATION. 


removal  of  the  cortex  the  bleeding  point  lies  plainly  in  view, 
and  the  htcmorrhage  is  easily  controlled  by  a  firm  compress 
of  iodoform  gauze.  This  is  held  by  an  assistant,  and  the  sur- 
geon finishes  the  operation  as  though  nothing  untoward  had 
happened.  Haemorrhage  from  the  sinus  is  no  more  severe 
than  that  from  one  of  the  large  venous  trunks  of  the  upper 
extremity,  and  the  possible  untoward  results  which  may  fol- 
low a  wound  of  this  vessel  will  depend  upon  the  imperfect 
exposure  of  the  bleeding  point  rather  than  upon  the  loss  of 
blood  or  the  accidental  infection  through  the  sinus. 

Having  now  removed  all  softened  bone,  the  wound  may 
or  may  not  be  irrigated,  according  to  the  individual  choice 
of  the  surgeon.  I  am  inclined  to  favor  dry  cleansing.  The 
bony  cavity  is  packed  loosely  with  iodoform  gauze,  the  tam- 
pon in  the  canal  is  reapplied,  and  the  soft  parts  are  allowed 
to  fall  back  over  the  opening  in  the  bone,  their  edges  being 
separated  by  a  narrow  strip  of  gauze  onlv.  It  is  not  neces- 
sary to  pack  the  external  wound,  as  was  formerly  done,  and 
the  omission  certainly  renders  the  first  dressing  more  com- 
fortable. Any  points  which  bleed  upon  removal  of  the  pres- 
sure forceps  may  be  tied,  but  this  is  seldom  necessarv.  The 
dressing  is  completed  by  covering  both  the  wound  and  the 
ear  with  several  layers  of  dry  sterilized  gauze  and  cotton,  the 
whole  being  confined  in  place  by  a  bandage. 

In  cases  where  the  technique  has  been  perfect  it  is  not 
necessary  to  remove  the  dressing  under  five  or  six  days.  The 
necessity  of  changing  the  dressing  at  an  earlier  period  will 
be  indicated  by  a  rise  in  temperature  or  by  local  pain. 
Where  the  temperature  does  not  exceed  ioi°  at  any  time 
during  the  first  five  days,  or,  if  elevated,  is  not  persistent, 
the  dressing  need  not  be  changed. 

The  subsequent  treatment  is  simple.  At  the  first  dressing 
we  frequently  find  the  canal  absolutely  free  from  discharge. 
Unless  the  discharge  is  profuse,  either  from  the  canal  or  from 
the  wound,  irrigation  is  not  to  be  employed  at  the  subsequent 
dressings.  If  considerable  secretion  is  present  it  is  wise  to 
irrigate  the  parts  freely,  the  fluid  employed  being  introduced 
through  the  artificial  opening  and  allowed  to  pass  out  of  the 
meatus;  the  technique  of  the  dressing  is  the  same  as  at  the 
time  of  operation.  Where  the  lateral  sinus  has  been  opened, 
or  the  dura  exposed  in  any  other  location,  particular  care  is 
necessary  at  each  dressing  to  guard  against  local  infection. 


ACCIDKNTS    DURINC;    Ol'ERATlON. 


;2I 


the  exposed  dural  area  bciiij^  uncovered  tirst,  cleansed  and 
protected  with  a  gauze  pad,  after  which  the  packing  may  be 
removed  from  the  mastoid  portion  ot  the  wound  and  the 
dressing  done  as  above  directed. 

In  addition  to  wounding  the  sinus,  the  operator  may  oc- 
casionally expose  or  even  wound  the  dura  in  the  middle 
cranial  fossa.  Entering  the  cranial  cavity  at  this  point  can 
be  avoided  in  every  instance  if  the  cortex  is  not  removed 
above  the  level  of  the  superior  wall  of  the  canal.  When  the 
temporal  ridge  is  very  prominent  and  the  margin  of  the 
meatus  is  placed  so  far  below  this  as  to  render  adherence  to 
this  rule  almost  impossible,  the  operator  mav  deem  it  wise  to 
extend  the  opening  in  the  bone  slightlv  above  the  line  indi- 
cated. If  the  calvaiium  is  unusualh  tliin,  even  the  most 
careful  operator  mav  enter  the  cranial  cavitv.  It  will  seldom 
happen  that  the  dura  is  wounded  if  care  is  taken  to  remove 
the  bone  in  successive  thin  lamella?,  and  its  exj)()sure  does  no 
harm.  It  is  onlv  necessary  to  disintcct  the  parts  bv  means  of 
a  warm  i-to-5,ooo  bichloride  solution,  or  with  a  sponge  moist- 
ened in  the  same  fluid,  after  which  the  opening  is  covered  bv  a 
pad  of  gauze;  this  is  intrusted  to  an  assistant,  and  the  opera- 
tion completed  in  the  oixlinary  manner.  Where  the  dura  is 
wounded,  the  opening  in  the  bone  siiould  be  enlarged;  and  if 
the  membrane  has  been  perforated,  it  mav  be  wise  to  enlarge 
this  opening  so  as  to  thoroughly  cleanse  the  underlying 
parts.  After  this  the  dural  opening  is  closed  with  a  fine  gut 
suture  and  treated  in  the  manner  above  described.  With  a 
careful  operator  such  an  accident  is  absolutely  hariuless,  and 
in  no  wav  complicates  the  progress  of  the  case.  In  the  ma- 
jority of  instances  a  prominent  temporal  ridge  means  either  a 
sinus  situated  farther  forward  than  normal,  or  a  low  middle 
cranial  fossa,  and  the  surgeon  will  be  particularly  careful  to 
confine  himself  to  the  limits  of  safety  when  these  anatomical 
features  present. 

Since  the  squamous  plate  of  the  temporal  bone  is  more 
horizontal  in  infancv  than  in  adult  life,  and  the  manner  in 
which  the  fibrous  canal  is  applied  to  the  outer  surface  of  the 
squama  on  account  of  the  absence  of  the  bony  canal  at  birth, 
attention  should  be  given  to  certain  variations  which  must 
be  practiced  when  tiie  mastoid  of  a  very  voung  child  is  to 
be  operated  upon.  At  birth,  since  the  fibro-cartilaginous 
meatus  along  its  superior  aspect  is  applied  to  the  external 
35 


522 


THE    MASTOID    OPERATION. 


surface  of  the  squama,  the  line  of  attachment  of  the  auricle 
to  the  skull  lies  at  a  much  higher  level  than  does  the  mem- 
brana  tympani,  and  the  superior  extremity  of  an  incision 
alonof  the  line  of  auricular  attachment  would  lie  at  a  much 
higher  level  than  the  upper  border  of  the  tympanic  ring 
(Fig.  122).  The  relative  position  of  the  parts  at  the  line  of 
auricular  attachment  is  misleading,  since,  when  the  anterior 
flap  is  pulled  forward,  the  fibro-cartilaginous  tube  constitut- 
ing the  meatus  is  attached  so  firmly  above  and  behind  as  to 
frequentlv  mislead  the  operator  and  cause  him  to  think  that 
the  margin  of  the  annulus  has  been  exposed.  If  the  bone  is 
perforated  without  exposing  the  posterior  limb  of  the  annulus 
clearly,  and  making  out  the  exact  situation  of  the  prominent 
posterior  tubercle,  both  by  touch  and  by  inspection,  the 
operator  may  accidentally  open  the  middle  cranial  fossa  in- 
stead of  the  pneumatic  space  of  the  mastoid  and  middle  ear. 
The  superior  and  posterior  attachments  of  the  meatus  should 
be  separated  carefully  from  the  squama  after  the  primary 
incision  until  the  posterior  tympanic  tubercle  is  reached 
and  the  canal  merges  into  the  drum  membrane.  It  is  often 
well  to  incise  the  fibrous  tube  transversely  for  a  short  distance, 
in  order  that  a  clear  view  mav  be  obtained  of  the  membrana 
tympani  and  render  an  error  impossible.  If  the  bony  cavitv 
is  entered  just  behind  this  tubercle  and  close  to  it,  the  antrum 
will  be  opened,  after  which  it  will  be  easy  to  chip  awav  the 
external  table  for  a  considerable  distance  forward  and  up- 
ward, thus  exposing  the  tympanic  vault  (Fig.  122).  It  is  wise, 
however,  to  make  it  a  rule  to  never  remove  the  outer  layer  of 
bone  at  a  higher  level  than  the  posterior  tvm})anic  tubercle  as 
a  primary  procedure.  The  depth  of  the  middle  cranial  fossa 
varies  considerably  in  different  subjects,  but  always  lies  above 
the  point  named.  The  exact  conformation  of  the  parts  in  any 
individual  case  is  easilv  made  out  when  access  is  once  gained 
to  the  pneumatic  spaces,  after  which  the  operator  will  adapt 
his  operation  to  the  anatomical  conditions  present.  The 
external  wall  of  the  tvmpanic  vault  at  birth  occupies  in  real- 
ity the  position  of  its  inferior  wall  in  adult  life,  owing  to  the 
change  in  direction  taken  by  the  squamous  plate  as  develop- 
ment progresses.  The  vault  will  therefore  be  entered  with 
very  little  trouble  close  above  the  line  of  attachment  of  the 
membrana  superiorly.  Another  word  of  caution  is  also 
proper   regarding   the    initial    incision.       Since    the    mastoid 


POSSIBLE    DIFFICL'LTIKS. 


523 


squamous  suture  is  not  ossified  at  birth,  and  frequently  pre 
sents  large  dehiscences  tilled  bv  hbi"o-cartilage,  the  knife,  in 
making  the  initial  incision,  should  myt  be  pressed  with  any 
f(jrce  upon  the  bone,  but  the  soft  parts  should  be  divided 
slowly  until  the  bone  is  exposed  throughout  the  line  of  in- 
cision. Firm  pressure  upon  the  scaljjel  might  easily  result  in 
plunging  it  into  one  of  these  dehiscences,  causing  it  to  enter 
the  cranial  cayity.  The  utmost  gentleness  should  also  be  ob- 
served in  dissecting  up  the  periosteum  and  turning  the  ante- 
rior flap  forward,  for  the  same  reason. 

In  every  instance,  then,  either  in  adults  or  in  children,  no 
procedure  should  be  instituted  for  the  removal  of  osseous 
tissue  until  the  posterior  and  superior  margins  of  the  bonv 
canal  are  not  only  accessible  to  the  finger  but  plainly  in  view. 
and  the  soft  parts  should  be  so  retracted  that  the  landmarks 
may  be  always  under  the  eye  of  the  surgeon  throughout  the 
entire  operation. 

The  facial  nerve  as  it  crosses  the  tympanic  cavity  is  occa- 
sionally wounded  in  cases  of  sclerosis  where  the  bone  has 
been  removed  to  a  sufficient  depth  to  cx|)Ose  the  internal 
wall  of  the  middle  ear.  The  aqua?ductus  Fallopii  lies  within 
the  middle  ear,  and  consc(]uently  it  is  impossible  to  wound  it 
until  the  operation  is  really  comj)lcted  and  free  communica- 
tion established  with  the  t\-m])anuni.  It  is  wise,  after  per- 
forating the  bone  to  a  depth  of  seven  eighths  of  an  inch,  or 
perhaps  a  little  less,  to  pass  a  j)robe  bent  at  a  right  angle  into 
tiie  external  auditory  meatus,  and  carry  the  angular  j)orti(jn 
upward  and  backward  into  the  tympanic  vault,  in  which  jjosi- 
tion  it  is  to  be  held.  The  operator  then  has  (jnly  to  continue 
the  removal  of  bone  until  the  artificial  opening  exposes  this 
probe  within  the  tympanum.  A  wound  to  the  external  semi- 
circular canal  is  more  unlikely  to  occur  than  one  of  the  facial 
nerve.  The  canal  lies  immediately  above  the  aqueduct,  and 
can  only  be  injured  when  the  opening  is  made  exceedingly 
high.  When  in  any  doubt  as  to  the  advisability  of  perforat- 
ing more  deeply  on  account  of  the  possibility  of  injuring 
either  of  these  structures,  the  plan  usually  followed  is  to  re- 
move that  portion  of  the  posterior  wall  of  the  canal  lying 
immediately  in  front  of  the  artificial  opening.  The  canal 
must  lead  into  the  middle  ear,  and  the  removal  of  this  bony 
partition  until  the  tympanum  is  reached  renders  the  comple- 
tion of  the   procedure   absolutely  safe.     In  these   cases   that 


524 


THE    MASTOID    OPERATION. 


portion  of  the  bony  posterior  wall  at  the  inner  extremity  of 
the  canal,  made  up  of  compact  osseous  tissue,  should  be  left, 
since  it  is  possible  to  wound  the  facial  nerve  under  these  con- 
ditions if  the  entire  posterior  wall  is  removed.  Injury  to  the 
facial  nerve  is  not  a  serious  accident,  function  being  restored 
in  from  three  to  five  weeks,  in  most  cases,  under  the  use  of 
the  faradic  current. 

In  cases  of  cholesteatoma  the  operation  is  modified  to  this 
extent,  that  the  partition  between  the  meatus  and  the  artificial 
opening-  in  the  mastoid  is  always  removed.  The  technique 
of  the  operation  consists  in  opening  the  mastoid  antrum  and 
obliterating  the  walls  of  the  cells  in  the  manner  already  de- 
scribed. The  upper  extremity  of  the  cutaneous  incision  is 
then  extended  slightly  downward  to  a  point  just  above  the 
tragus,  while  below  it  is  curved  forward  beneath  the  lobule  to 
a  point  immediately  below  the  antitragus.  With  the  perios- 
teum elevator  the  fibro-cartilaginous  canal  and  the  periosteum 
of  the  bonv  meatus  are  carefully  separated  from  their  osseous 

attachments.  The  posterior 
wall  is  then  divided  trans- 
versely, by  means  of  a  knife, 
as  close  to  the  membrana 
tympani  as  possible,  and  bv 
traction  upon  the  auricle 
the  membranous  funnel-like 
flap,  composed  of  the  pinna 
and  the  attached  meatus,  is 
drawn  outward  as  a  whole, 
thus  exposing  to  direct  in- 
sfiection  the  bonv  canal,  and, 
if  the  drum  membrane  is  de- 
stroved,  the  tvmpanic  cavitv 
and  its  contents.  Where  the 
ossicles  are  carious,  these 
are  removed,  after  which 
the  partition  between  the 
mastoid  opening  and  the  me- 
atus is  broken  down,  and 
the  margin  of  the  tympanic  ring,  above  and  posteriorly,  chis- 
eled away,  until  the  probe,  bent  at  a  right  angle  and  car- 
ried upward  into  the  tympanum,  meets  no  obstruction  at  the 
margin  of  the  ring  when  withdrawn  from  the  canal.     To  ren- 


\ 


1-  ]'..  I  ~u. —  1  liL'  tyiniKiiiic  \:iuit  ami  ils  con- 
tents exposed  by  the  removal  of  its  outer 
wall,  and  the  division  of  the  tihrous  me- 
atus transversely  close  to  the  membrana 
tympani.  (Author's  specimen,  natural 
size.) 


HKRC.MANNS    OPERATION. 


525 


der  the  healini;-  more  rapid,  the  hbro-cartilaginous  portion  of 
the  meatus  which  has  been  drawn  forward  is  now  sp)lit  along- 
its  posterior  asi)ect  bv  a  horizontal  incision  extending  from 
its  point  of  detachment  close  to  the  membrana  tvmpani  to 
the  root  of  the  auricle,  thus  forming  two  triangidar  tfajis, 
\vhich  mav  be  pressed  backward  into  the  large  bony  cavity 
remaining  after  the  operation.  These  flaps  are  held  in  posi- 
ticjn  by  a  tampon  inserted  into  the  canal,  and  by  adhering  to 
the  denuded  bone  facilitate  the  rapid  deyeloj)ment  of  a  cu- 
taneous lining  to  the  cavity.  The  soft  parts  pc^steriorly  are 
then  sutured,  in  order  that  better  approximation  may  be  ef- 
fected, all  drainage  taking  place  through  the  meatus.  It  is 
wise  to  introduce  a  moderate-sized  drainage  tube  into  the 
canal  as  far  as  the  membrana  tympani.  to  prevent  deformilv 
of  the  meatus,  which  might  easily  occur  from  a  slight  dis- 
placement of  the  outer  segment.  This  tube  may  be  removed 
at  the  first  dressing,  and  need  not  be  replaced.  After  the  sec- 
ond day  a  tampon  will  support  the  parts  sufficiently. 

In  cases  where  the  mastoid  cells  and  the  vault  ol  the  tym- 
panum have  become  involved  in  an  inilammatorv  process, 
and  drainage  through  the  external  auditory  meatus  is  insuffi- 
cient, Bergmann  has  advised  a  procedure  for  the  evacuation 
of  the  retained  ]»us  and  the  removal  of  carious  bone.  Ihe 
anatomical  conditions  rendering  this  possible  are  found  in 
the  peculiar  method  in  which  the  temj^oral  bone  develops. 
It  will  be  remembered  that  during  development  the  squa- 
mous portion  in  the  region  of  the  tvmj)anic  cavity  sepa- 
rates into  two  lamella?,  the  inner  forming  a  jjortion  of  the 
tympanic  roof,  while  the  other,  extending  in  the  direction 
downward  and  somewhat  inward,  hlls  up  the  ga|)  between 
the  free  extremities  of  the  tvmj^anic  ring,  thus  completing 
the  curved  outline  superiorly.  We  also  recall  that  during 
the  successive  periods  of  childhood  and  adolescent  life  the 
growth  of  the  squama  progresses  in  such  a  manner  that  the 
roof  of  the  canal  extends  outward  in  almost  a  horizontal 
direction,  so  that  the  structure  which  in  the  child  consists 
merely  of  a  bony  arch,  in  the  adult  has  been  transformed 
into  a  horizontal  bony  lamella.  The  outer  wall  of  the  tym- 
panic vault  lies  at  the  angle  formed  by  the  divergence  of  the 
internal  and  external  lamellas  of  the  squama.  It  is  evident, 
therefore,  that  if  an  artificial  opening  is  made  parallel  to  the 
roof  of  the   canal  between  these  two  lamellas  it  will  enter 


526 


THE    MASTOID    OPERATION. 


the  vault  of  the  tympanum.  Bergmann  exposes  the  supero- 
posterior  margins  of  the  meatus  by  an  incision  close  to  the  at- 
tachment to  the  auricle,  and  separates  the  iibro-cartilaginous 
canal  together  with  the  periosteum  of  the  osseous  meatus 
along  its  superior  and  posterior  aspects,  thus  exposing  the 
superior  margin  of  the  bony  canal.  By  means  of  a  chisel  the 
superior  wall  of  the  meatus  and  the  diploe  beneath  are  care- 
fully chiseled  awav,  following  the  upper  wall  of  the  meatus 
inward-  until  the  vault  of  the  tympanum  is  entered.  By  this 
procedure  direct  access  is  gained  to  that  portion  of  the  cavity 
lodging  the  malleo-incudal  articulation  (Fig.  150),  a  region 
which  is  especially  prone  to  be  the  seat  of  caries  in  chronic  sup- 
puration of  the  middle  ear.  Through  this  opening  the  ossicles 
can  be  removed,  the  t3'mpanic  roof  curetted  thoroughly,  and 
all  softened  bone  removed,  in  a  similar  manner,  from  the  other 
aspects  of  the  vault.  Bv  enlarging  the  opening  posteriorly, 
free  access  is  gained  to  the  mastoid  antrum  and  the  other 
mastoid  cells.  Bv  dividing  the  posterior  and  superior  wall  of 
the  fibrous  canal  in  such  a  manner  that  the  soft  parts  may  be 
crowded  into  the  bony  cavity  thus  thrown  into  the  canal,  the 
operator  succeeds  in  placing  that  series  of  pneumatic  spaces 
which  are  in  communication  with  the  tympanic  cavitv  under 
direct  ocular  inspection  from  the  meatus,  so  that  any  subse- 
quent caries  can  easily  be  dealt  with  without  recourse  to  a 
serious  operation.  Combined  with  the  operation  proposed 
by  Stacke,  already  described,  Bergmann's  method  forms  a 
valuable  means  of  securing  free  drainage,  and  of  removing 
all  carious  tissue  from  the  deeper  portions  of  the  ear.  It  is 
also  valuable  in  those  cases  where  the  lateral  sinus  lies  so  far 
forward  as  to  prevent  entering  the  mastoid  antrum  at  the  site 
of  election. 

The  technique  of  dressing  the  wound  is  the  same  as  that 
described  under  the  consideration  of  Stacke's  operation,  and 
must  vary  slightly  with  each  individual  case  according  to  the 
indications. 


PLATE   VIII. 


Exploration  of  the  Tympanic  Roof,  Lateral  Sinus,  and  Cerebellum. 


CHAPTHR     XX  1\. 

THE     SURCICAL    TKKAT.MKNT    OF    TIIK     IN  lk.\(  KAMAL 
COMri.KATlONS    (»F    AIRAI.    ST  I'lT  KA  IK  »N. 

W^IIKX  it  has  been  decided  that  the  intraciaiiial  structures 
are  involved  either  subsequently  to  an  ojteration  on  the  mas- 
toid or  when  the  case  first  conies  under  observation,  it  is  wise 
to  institute  surgical  measures  for  the  relief  of  the  condition. 
It  has  been  argued  that,  from  the  great  mortalitv  following 
such  measures,  thev  are  not  justifiable  ;  but  when  we  remem- 
ber that  the  only  chance  of  relief  lies  in  surgical  interference, 
it  seems  wrong  to  refuse  the  patient  this  opportunity. 

In  purulent  meningitis  surgical  interference  offers  less 
promise  than  in  ej)idural  or  cerebral  abscess,  or  in  sinus 
thrombosis,  when  ])ronipt  action  on  the  |)art  of  tiie  surgeon 
often  saves  life.  It  is  onlv  when  unmistakable  svmj»t<^ms  of 
extensive  meningitis  occur  that  we  shoukl  hesitate  in  per- 
forming an  operation  in  anv  of  these  cases. 

It  is  well,  in  imdeitaking  an  operation  for  the  relief  of  an 
intracranial  lesion  follow  ing  a  middle-ear  inflammation,  to  re- 
member the  advantage  ot  having  the  opening  in  the  soft  ]iarts 
sufTicientlv  ample  to  permit  of  extending  the  oj)ening  in  the 
skull  in  various  directions,  if  desirable,  without  enlarging  the 
cutaneous  incision. 

The  operator  mav  wish  to  explore  the  middle  fossa,  the 
sinus,  and  the  cerebellum  at  the  same  operation,  and  to  expose 
each  of  these  areas,  as  a  separate  procedure  would  entail  the 
expenditure  of  much  valuable  time.  It  is  wise,  therefore,  to 
expose  the  bony  surface  over  an  area  which  includes  the  vari- 
ous sites  of  election  for  entering  the  cavity  (Fig.  151).  The 
author  has  found  that  the  exposure  is  best  effected  bv  the 
displacement  of  a  semicircular  flap,  as  shown  in  Plate  VIII. 
This  flap  is  formed  by  extending  the  incision,  made  at  the 
time  of  the  mastoid  operation,  forward  along  the  zygoma  for 
a  distance  of  half  an  inch.  From  this  point  an  incision  is  made 
backward   to   the   occipital   protuberance.      This    incision    is 

^527) 


528    SURGICAL    TREATMENT    OF    AURAL    SUPPURATION. 

slightly  curved,  the  convexity  being  directed  upward;  from 
the  occipital  protuberance  the  incision  is  carried  vertically 
downward  to  the  level  of  the  tip  of  the  mastoid.  If  the  soft 
parts  are  now  dissected  up,  a  large  flap  can  be  turned  down 
upon  the  neck,  exposing  the  surface  of  the  cranium.  The  flap 
is  supplied  bv  the  vessels  which  enter  from  below,  and  the 


Fig.  151. — Lateral  aspect  of  skull  showing  the  relative  position  between  the  super- 
ficial landmarks  and  the  contents  of  the  cranial  cavity,  x,  x',  Reed's  base  line. 
This  is  a  horizontal  line  drawn  through  the  middle  of  the  external  meatus  and 
the  lower  border  of  the  orbit.  /,  Tentorium  ;  c,  Situation  of  trephine  opening 
for  exposure  of  temporo-sphenoidal  lobe  ;  d.  Situation  of  trephine  opening  for 
examining  the  roof  of  the  tympanum  ;  <i.  Site  for  opening  mastoid  antrum  ;  </, 
Site  of  election  for  ex]iosing  the  lateral  sinus  ;  c",  Site  of  election  for  opening 
cerebellar  abscess.  (For  convenience  the  base  line  is  divided  into  eighths  of  an 
inch.     Modified  from  Starr.) 

danger  of  sloughing  is  avoided.  All  attached  muscles  are 
divided  longitudinalh',  and  hence  their  action  is  in  no  way 
destroyed. 

In  dissecting  up  this  flap,  the  periosteum  is  not  detached  ; 
this  is  undisturbed,  except  where  the  bony  wall  is  removed  to 
effect  an  entrance  to  the  cranial  cavity. 

A.  Sinus  Thrombosis. — Where  the  mastoid  has  been  previ- 
ously opened,  the  simplest  means  of  exposing  the  lateral  sinus 
is  to  enlarge  the  original  opening  backward  and  downward, 
and  expose  the  dura.  This  opening  may  be  continued  back- 
ward as  far  as  the  occipito-temporal  suture,  and  the  opening 


SINUS   THROMBOSIS— EPIDURAL   ABSCESS. 


529 


thus  made  will  in  every  case  be  of  ample  size  to  admit  of  suf- 
ficient access  to  the  sinus  for  diagnostic  or  therapeutic  pur- 
poses. This  opening  also  enables  an  exploration  of  the  cere- 
bral and  cerebellar  fossas.  If  no  previous  operation  has  been 
performed  upon  the  mastoid  process,  it  will  usually  be  wise  to 
clear  out  the  mastoid  as  the  primary  step  of  the  procedure. 
If  we  wish,  however,  to  expose  the  sinus  alone,  this  may  be 
done  by  removing  a  button  of  the  bone  with  the  trephine,  the 
centre  pin  of  the  instrument  being  located  at  a  point  seven 
eighths  of  an  inch  behind  the  centre  of  the  bony  meatus  and 
a  quarter  of  an  inch  above  the  horizontal  plane  through  this 
point  (Fig,  151,  d)\  the  opening  may  be  enlarged  with  the 
rongeur,  if  necessary.  After  the  venous  channel  has  been  ex- 
posed, the  presence  of  a  clot  is  determined  either  by  the  sense 
of  touch  or  by  the  insertion  of  a  previously  sterilized  hypo- 
dermic needle.  If  an  infectious  thrombus  is  present,  foul- 
smelling  pus  or  decomposed  blood  is  withdrawn,  while,  if  the 
channel  is  normal,  fluid  blood  alone  enters  the  syringe. 

To  remove  an  infectious  thrombus,  the  wall  of  the  sinus  is 
to  be  freely  incised  and  its  cavity  freed  of  the  decomposed  clot 
bv  the  delicate  use  of  the  curette.  It  is  wise  to  continue  this 
cleansing  process  until  rather  free  haemorrhage  follows.  The 
cavity  is  now  packed  with  iodoform  gauze.  Where  the  clot 
has  extended  downward  into  the  internal  jugular  vein,  as  evi- 
denced by  tenderness  along  the  anterior  border  of  the  sterno- 
mastoid  muscle  and  the  presence  of  a  tense,  cordlike  structure 
occupying  the  situation  of  the  jugular  vein,  it  is  not  sufificient 
to  disinfect  the  sinus  alone,  but  the  clot  from  the  jugular  must 
also  be  removed,  to  prevent  further  systemic  infection.  To  do 
this,  it  is  necessary  to  expose  the  internal  jugular  in  the  neck. 
It  is  then  divided  between  two  ligatures,  after  which  the  su- 
perior portion,  containing  the  thrombus,  is  removed  in  exactly 
the  same  manner  as  that  in  the  lateral  sinus.  Any  large  trib- 
utary vein  exposed  during  the  operation  must  be  tied  before 
the  jugular  is  divided.  The  infected  area  is  thus  completely 
cut  off  from  the  general  circulation,  and  this  plan  of  treatment, 
when  instituted  early  enough,  is  certainly  efficient.  If  compli- 
cated, as  only  too  often  happens,  by  a  collection  of  pus  deep 
in  the  cerebral  substance,  or  by  the  presence  of  a  diffuse  puru- 
lent meningitis,  death  will  follow  in  spite  of  the  removal  of  the 
source  of  systemic  infection. 

B.  Epidural  Abscess. — For  the  relief  of  pus  between  the 
36 


■)30 


SURGICAL    TREATMENT    OF    AURAL    SUPPURATION. 


dura  mater  and  the  osseous  wall  of  the  cranium  it  is  only 
necessary  to  perforate  the  skull  in  order  to  evacuate  the  fluid. 
The  decision  as  to  the  exact  location  of  such  an  abscess  must 
always  be  largely  a  matter  of  conjecture,  and  it  is  well  to 
remember  that,  out  of  a  series  of  cases  reported,  the  most 
usual  location  has  been  either  in  the  posterior  or  in  the  middle 
cranial  fossa  in  the  order  named.  The  operative  technique 
consists  in  the  removal  of  the  inner  table  of  the  skull,  over 
the  site  of  the  mastoid  opening,  extending  it  as  much  as  is 
necessary  to  expose  the  dura  in  the  posterior  fossa.  A  probe 
is  then  inserted  between  the  meninges  and  bone  and  passed 
gently  in  every  direction,  to  discover,  if  possible,  the  location 
of  the  purulent  focus.  Failing  in  this,  the  middle  cranial  fossa 
should  be  explored  ;  this  may  be  done  by  enlarging  the  origi- 
nal opening  bv  means  of  the  rongeur.  Owing  to  the  thick- 
ness of  the  skull  in  this  region,  it  is  wiser  to  perforate  a  second 
time  than  to  extend  the  previous  opening.  For  this  purpose 
the  cutaneous  incision  is  carried  first  upward,  and  then  for- 
ward and  downward  to  the  zygoma.  By  means  of  the  elevator 
the  soft  parts  are  raised  from  the  bone  and  the  trephine  ap- 
plied at  a  point  one  inch  above  the  centre  of  the  external 
canal  (Fig.  151,  d);  the  perforation  may  be  made  by  means  of 
the  gouge  or  chisel,  instead  of  the  trephine,  if  the  operator 
prefers.  This  admits  of  exploration  of  the  entire  tympanic 
roof,  and  the  probe  may  be  carried  along  the  anterior  surface 
of  the  petrous  portion  of  the  temporal  bone  from  its  base  to 
its  apex.  In  many  cases  the  finger  may  be  used  for  the  pur- 
pose of  exploration.  The  exposure  of  the  middle  cranial  fossa 
by  removal  of  the  tympanic  roof  seems  to  me  more  difficult 
than  by  the  manner  above  described,  and  the  space  gained  is 
certainly  much  less.  Pus  being  encountered,  it  is  only  neces- 
sary to  thoroughly  wash  out  the  cavity  and  secure  drainage 
by  the  insertion  of  strips  of  gauze,  the  external  wound  being 
allowed  to  heal  bv  granulation.  If  we  have  been  fortunate 
enough  to  locate  the  abscess,  these  cases  usually  terminate 
favorably  ;  all  untoward  symptoms  disappear  upon  evacua- 
tion of  the  fluid,  and  prompt  recovery  follows. 

C.  Cerebral  Abscess. — There  may  be  localizing  svmptoms 
sufl^iciently  definite  to  point  to  the  exact  site  of  the  lesion ; 
when  this  is  the  case,  the  cranial  cavity  is  entered  over  the 
proper  area  either  by  means  of  the  trephine  or  chisel.  In 
case  the  situation  is  believed  to  be  near  the  mastoid  opening, 


CEREBRAL    ABSCESS. 


531 


it  is  only  necessary  to  enlarge  the  previous  wound.  Only  too 
frequently  we  are  in  the  dark  as  to  the  exact  situation  of  the 
purulent  collection,  and  the  operation  is  exploratory  in  char- 
acter, the  diagnosis  depending  rather  upon  the  absence  of 
definite  symptoms  than  upon  the  presence  of  those  indicative 
of  the  involvement  of  any  one  particular  region. 

The  area  best  adapted  to  exploration  of  the  cranial  cavity 
is  one  the  centre  of  which  lies  an  inch  and  a  quarter  behind 
the  centre  of  the  canal  and  an  inch  and  a  quarter  above  its 
horizontal  plane  (Fig.  151,  f).  Through  a  free  opening  here 
we  are  able  to  explore  the  temporo-sphenoidal  lobe,  the  pos- 
terior cerebral  lobe,  and  the  entire  neighboring  epidural 
space  as  well.  From  this  point  as  a  centre,  the  opening 
may  be  extended  either  forward  or  backward,  as  may  seem 
desirable  during  the  progress  of  the  operation,  and  access 
gained  to  almost  everv  part  of  the  cavity  of  the  cranium. 
This  central  point  should  be  marked  upon  the  skull  before  the 
integument  is  raised;  this  is  done  bv  piercing  the  soft  parts 
with  a  stout  scalpel  or  by  a  small  drill,  so  as  to  leave  a  mark 
upon  the  bony  surface  recognizable  after  reflecti(3n  of  the 
soft  parts.  The  area  should  be  exposed  bv  reflecting  the 
semilunar  flap  downward,  as  before  described.  The  point 
for  the  application  of  the  trephine  will  lie  at  about  the  centre 
of  the  exposed  area.  The  trephine  may  be  of  large  size,  to 
permit  of  the  parts  being  explored  in  every  direction  for  a 
considerable  distance,  and  to  allow  free  manipulation  of  the 
divided  structures ;  or,  as  I  prefer,  a  small  trephine  may  be 
used,  and  the  opening  enlarged  with  the  rongeur.  After 
exposing  the  dura  and  finding  no  extradural  collection,  a 
dural  flap  is  to  be  raised  and  the  probe  passed  in  every  direc- 
tion between  the  dura  and  the  surface  of  the  brain.  Care 
should  be  taken  to  locate  the  line  of  incision  through  the  dura 
so  as  to  avoid  an}-  large  venous  trunks,  as  haemorrhage  from 
these  will  complicate  the  operation  considerably.  If  we  have 
no  indication  of  the  exact  situation  of  the  abscess,  a  large  aspi- 
rating needle,  properly  disinfected  and  attached  to  a  good- 
sized  hypodermic  syringe,  mav  be  thrust  into  the  brain  sub- 
stance in  various  directions  for  the  purpose  of  exploration. 
In  general,  these  punctures  should  be  made  first  downward, 
forward,  and  inward,  the  piston  of  the  syringe  being  drawn 
up  as  soon  as  the  needle  enters  the  brain  tissue,  and  the  point 
of  the  instrument  advanced  slowly,  so  that  any  thin-walled 


532   SURGICAL   TREATMENT   OF   AURAL   SUPPURATION. 

abscess  may  not  be  overlooked.  In  the  same  manner  we  re- 
peat this  step  by  passing  the  needle  directly  inward,  forward 
and  inward,  and  downward,  backward  and  inward.  The 
traumatism  sustained  by  the  brain  tissue  from  these  punctures 
seems  to  be  of  but  little  importance. 

If  one  of  the  lateral  ventricles  is  entered,  the  syringe  fills 
with  ventricular  fluid,  and,  as  in  all  intracranial  diseases 
attended  with  venous  hypersemia,  the  ventricular  fluid  is 
increased  in  amount ;  the  withdrawal  of  this  fluid  is  certainly 
of  therapeutic  value.  We  should  also  remember  that  a  cere- 
bral abscess  may  rupture  into  the  ventricles,  and  then  these 
cavities  must  be  opened  and  drained  in  order  to  secure  the 
desired  end. 

For  exploration  of  the  cerebellum,  the  opening  through 
the  skull  should  be  located  an  inch  and  a  half  behind  the 
centre  of  the  meatus  and  a  quarter  of  an  inch  below  its  hori- 
zontal plane  (Fig.  151,  <-).  The  technique  is  the  same  here  as 
when  the  cranial  cavity  is  opened  in  other  situations.  The 
value  of  the  aspirating  needle  as  an  instrument  of  exploration 
has  perhaps  been  overrated.  The  pus  found  in  these  ab- 
scesses is  frequently  so  thick  that  it  will  not  pass  through 
the  needle  even  if  it  be  one  of  large  size  ;  and  after  the  menin- 
geal flap  has  been  raised  it  is  quite  as  wise  to  use  a  simple 
grooved  exploring  needle,  as  the  instrument  suggested  above. 
If  pus  is  found,  the  brain  substance  itself  is  incised  freely  with 
the  probe-pointed  bistoury,  the  contents  of  the  abscess  evacu- 
ated, and  a  gauze  drain  inserted. 

If  the  dura  has  been  incised  extensively,  this  opening  may 
be  partially  closed  by  means  ot  fine  silk  sutures.  The  intra- 
cranial pressure  is  increased,  no  matter  what  the  exact  char- 
acter  of  the  lesion  may  be,  and  difficulty  may  be  experienced 
in  preventing  a  hernia  cerebri,  the  cerebral  matter  protrud- 
ing so  much  through  the  opening  in  the  skull  as  to  render 
suture  of  the  dural  flap  somewhat  difficult.  An  evacuation 
of  the  ventricular  fluid  relieves  the  tension  sufficiently  to 
permit  an  apposition  of  the  edges  of  the  divided  dura.  The 
pericranium  is  replaced,  and  either  not  sutured  at  all  or  at 
the  angles  of  the  wound  simplv.  The  wound  is  then  dressed 
in  the  ordinary  manner. 

D.  Purulent  Meningitis. — In  instituting  operative  proce- 
dures for  a  purulent  meningitis,  the  rational  svmptoms  seldom 
aid  us  in  deciding  the  area  involved.     The  first  step,  there- 


PURULENT    MENINGITIS. 


533 


fore,  should  be  to  thoroughly  open  the  mastoid  and  tympanic 
vault,  and,  if  the  site  of  perforation  into  the  cranium  is  dis- 
covered, the  cavity  is  to  be  entered  by  enlarging  this  open- 
ing. It  no  sinus  is  found,  or  if  there  is  no  localized  area  of 
caries  which  suggests  the  site  of  the  meningeal  inflammation, 
the  tympanic  roof  should  be  explored  by  entering  the  cranial 
cavity  above  the  meatus.  If  no  evidence  of  meningitis  is 
found  here,  the  inner  table  should  be  removed  in  the  area  of 
the  mastoid  wound,  and  the  opening  enlarged  bv  the  rongeur 
or  chisel  until  the  sinus  is  exposed.  The  anterior  margin  of 
the  sinus  will  be  encountered  about  half  an  inch  behind  the 
posterior  margin  of  the  meatus,  as  a  rule.  Any  focus  of  in- 
flammation is  to  be  thoroughly  cleansed  bv  means  of  a  warm 
solution  of  bichloride  of  mercury  (i  to  3,000),  after  which  the 
surface  is  to  be  covered  with  iodoform  gauze.  The  (niter 
wound  is  packed  in  the  same  manner,  and  the  parts  covered 
with  a  dressing  of  bichloride  or  sterilized  <rauzc. 


SECTION    IV. 
DISEASES   OE   THE   PERCEPTIVE   MECHANISM. 

(535) 


DISEASES    OF 
THE    PERCEPTIVE    MECHANISM. 


The  sound-perceiving  apparatus  includes  the  medullary 
nuclei  of  the  auditory  nerve,  and  the  nerve  fibres  joining 
these  to  the  cortical  areas  in  the  first  and  second  temporal 
convolutions.  Passing  from  the  medullary  centres  in  the  oppo- 
site direction,  it  includes  the  trunk  of  the  auditory  nerve  and 
its  terminal  filaments  specialized  in  the  labvrinth  for  sound 
perception. 

In  addition  to  the  perception  of  sound,  tiic  auditory  nerve 
trunk  contains  a  distinct  group  of  fibres  which  preside  over 
the  equilibrium  of  the  body.  The  terminal  filaments  of  these 
fibres  are  distributed  to  the  semicircular  canals,  while  their 
cortical  areas  within  the  cranium  are  found  within  the  cere- 
bellum. Interference  with  the  perceptive  mechanism  is  con- 
sequently attended  in  most  instances  by  some  disturbance  of 
equilibrium.  This  may  be  so  slight  as  to  entirely  escape  the 
notice  of  the  patient  unless  his  attention  is  particularly  drawn 
to  it,  or  it  may  be  the  principal  disorder  for  which  he  seeks 
relief.  Interference  either  with  ccpiiiibrium  or  with  the  func- 
tion of  audition,  characterized  by  an  impairment  in  this  func- 
tion or  its  perversion,  mav  depend  upon  organic  changes  in 
any  portion  of  the  mechanism  specialized  for  this  particular 
purpose.  It  may  be  also  of  reflex  origin,  no  structural  change 
having  taken  place  in  any  portion  of  the  ear,  but  an  affection 
of  some  remote  organ  influencing  by  reflex  action  this  par- 
ticular part  of  the  economy. 

It  follows,  therefore,  that  the  history  of  the  individual  is 
of  particular  importance  in  connection  with  diseases  of  this 
portion  of  the  auditory  apparatus.  Some  illness  in  early  life, 
or  a  slight  traumatism,  might  entirely  escape  the  mind  of  the 
patient,  as  having  no  bearing  upon  the  condition  for  which  he 
seeks  advice,  but  may  often  lead  us  to  a  correct  interpretation 

(537) 


538 


DISEASES   OF   THE    PERCEPTIVE    MECHANISM. 


of  the  cause  of  a  symptom.  The  physical  examination  of  the 
ear  is  really  a  very  small  part  of  the  investigation  in  these 
cases,  and  one  who  confines  himself  to  this  special  examina- 
tion alone  must  invariably  fall  into  error  in  his  attempts  to  cor- 
rectly explain  the  cause  of  many  of  the  symptoms.  Certain 
phenomena  are  characteristic  of  involvement  of  this  portion 
of  the  organ  of  hearing.  The  hearing  power,  in  cases  where 
the  perceptive  mechanism  is  principally  involved,  is  either 
profoundly  affected  or  but  slightly  changed,  the  moderate 
grades  of  impairment  depending  usually  upon  diseases  of  the 
conducting  apparatus.  Tinnitus  is  almost  alwavs  present, 
and,  if  carefully  investigated,  we  shall  usually  find  a  history 
of  attacks  of  vertigo.  I  am  of  the  opinion  that  sufficient  stress 
is  never  laid  upon  the  S3-mptoms  dependent  on  labyrinthine 
involvement  in  the  ordinary  cases  of  diseases  of  the  conduct- 
ing apparatus.  A  secondary  labyrinthine  disturbance  may 
occur  as  a  complication  or  as  a  sequel  of  changes  within  the 
middle  ear,  and  yet  of  itself  require  no  treatment  other  than 
that  directed  to  the  t3'mpanum.  This  latter  fact  does  not 
make  it  less  a  labyrinthine  affection,  the  removal  of  the  cause 
being  the  rational  method  for  overcoming  this  disturbance. 

With  reference  to  the  impairment  of  hearing,  low-pitched 
sounds  are  perceived  better  than  those  of  high  pitch,  particu- 
larly if  a  preceding  disease  of  the  middle  ear  has  led  to  the 
involvement  of  the  nervous  apparatus.  Marked  variations 
in  the  degree  of  impairment,  dependent  upon  climatic  changes 
or  mental  or  physical  fatigue,  are  quite  as  characteristic  of  a 
pathological  condition  located  here  as  they  are  of  middle-ear 
changes. 

Where  the  power  of  audition  changes  with  the  weather, 
being  worse  on  damp  days  and  improving  as  the  atmosphere 
clears,  it  is  usually  supposed  that  the  disturbance  depends 
upon  a  middle-ear  affection.  If  we  remember  the  intimate 
relation  between  the  venous  circulation  within  the  turbinated 
bodies  and  the  venous  return  current  from  the  cochlea,  we 
can  easily  understand  how  a  turgescence  of  the  nasal  mucous 
membrane  will  cause  a  venous  stasis  within  the  labyrinth. 
No  better  proof  can  be  afforded  that  this  is  the  case  than  the 
marked  relief  to  subjective  noises  often  observed  when  the 
turbinated  tissues  are  exsanguinated  by  the  use  of  cocaine. 

The  duration  of  the  affection  and  its  progress  also  aid  us 
in  determining  its  site.     Primary  lesions  of  the  perceptive 


GENERAL   OBSERVATIONS.  53c) 

apparatus  either  remain  quiescent  or  improve  to  a  certain 
extent  spontaneously  as  time  progresses,  excepting,  of  course, 
those  dependent  uDon  a  specific  inflammation.  Secondary 
changes  within  the  receptive  apparatus,  organic  in  character, 
are  usually  due  to  some  chronic  affection  of  the  middle  ear 
either  of  the  same  or  opposite  side.  When  the  opposite  or- 
gan is  primarily  affected  the  impairment  of  function  advances 
rapidly,  as  a  rule,  and  here  the  history  of  previous  tj-mpanic 
disease  renders  diagnosis  clear.  The  character  of  the  subjec- 
tive noises  is  of  aid  in  locating  the  lesion,  in  that  the  particu- 
lar character  of  the  sound  points  to  the  special  part  of  the 
labyrinth  involved.  Almost  invariably  in  the  secondary  laby- 
rinthine changes  due  to  chronic  suppurative  or  nonsuppura- 
tive otitis  media  the  subjective  noises  are  high-pitched  in  char- 
acter, and  assume  a  deeper  quality  only  after  they  have  per- 
sisted for  a  long  period.  The  complete  cessation  of  tinnitus 
in  these  secondary  cases  probably  indicates  that  the  laby- 
rinthine invasion  has  ceased  to  progress,  and  the  length  of 
time  during  which  the  patient  has  been  free  from  subjective 
noises  is  of  aid  in  determining  the  probability  of  restoring 
the  parts  to  their  normal  condition  by  treatment.  Vertigo,  if 
severe,  points  to  a  sudden  and  considerable  disturbance  with- 
in the  perceptive  mechanism,  as  at  the  onset  of  an  attack,  or 
to  an  aggravation  of  an  existing  condition.  Repeated  attacks 
of  giddiness  of  a  mild  character  would  indicate  that  at  these 
periods  the  labyrinthine  structures  or  the  higher  centres 
were  subjected  to  some  unusual  stimulation  either  from  the 
tympanum,  from  intracranial  changes,  or  of  a  reflex  character 
from  some  visceral  derangement.  The  effect  of  continued 
stimulation  of  the  nervous  mechanism  by  sonorous  vibrations 
— as  when  the  patient  is  subjected  to  the  noise  of  a  railway 
train  for  a  number  of  hours,  or  has  taxed  himself  to  the  ut- 
most in  listening  to  conversation  which  it  has  been  difficult 
for  him  to  hear — is  of  value  in  diagnosis.  Prolonged  excita- 
tion of  any  nerve,  at  length  renders  it  less  susceptible  to  the 
particular  stimulus  which  has  fatigued  it.  When  the  nerve 
structures  are  in  an  abnormal  condition  they  become  fatigued 
more  easily  than  when  in  a  state  of  health  ;  and  a  patient  will 
often  be  found  to  be  more  deaf  after  a  prolonged  railway  jour- 
ney than  when  he  has  been  comparatively  quiet.  Physical 
fatigue  may  indirectly  bring  about  the  same  result.  It  is 
sometimes  said  that  the  paracusis  Willisii  is  characteristic  of 


540         DISEASES    OF    THE    PERCEPTIVE    MECHANISM. 

involvement  of  the  nervous  apparatus.  This  may  be  true 
when  the  patient  is  subjected  to  a  noise  for  a  short  time  ;  but 
if  the  stimulation  is  continued,  the  nerve  becomes  fatigued 
and  less  responsive  to  stimuli.  The  reverse  takes  place  when 
the  nerves  preserve  their  integrity  and  the  conducting  mech- 
anism is  at  fault. 

The  determination  of  the  special  part  of  the  perceptive 
mechanism  involved  must  remain  a  matter  of  doubt  in  a  cer- 
tain proportion  of  cases.  In  general,  it  may  be  said  that  the 
history  of  a  previous  middle-ear  affection,  of  an  acute  infec- 
tious disease,  or  of  a  traumatism  with  a  slight  impairment  of 
hearing,  points  to  an  involvement  of  the  labyrinth.  On  the 
other  hand,  where  we  have  symptoms  referable  to  the  ear 
in  cases  giving  a  history  of  severe  injury  followed  by  an 
involvement  of  the  intracranial  structures,  as  evidenced  by 
other  symptoms,  or  where  there  are  other  manifestations  of 
cerebral  disturbance  at  the  time  of  the  examination — such  as 
local  paralysis,  psychic  phenomena,  etc. — we  should  suppose 
that  the  auditory  cortical  centres  had  suffered.  An  affection 
of  the  trunk  of  the  nerve  should  be  suspected  when  the  im- 
pairment is  to  an  extent  uniform,  or  affects  particularly  the 
perception  of  those  sounds  to  which  the  ear  is  most  frequently 
subjected,  since,  when  all  the  fibres  of  the  trunk  are  involved, 
the  fibres  which  are  most  constantly  used  will  be  most  seri- 
ously affected.  Marked  variations  in  sound  perception  de- 
pendent upon  excitement,  fatigue,  disturbance  of  the  prima 
viae,  etc.,  would  characterize  the  aural  affection  as  reflex. 
Bearing  these  various  points  in  mind,  we  should  always  se- 
cure the  general  history  in  every  case  of  aural  disease,  so  as 
to  obtain  data  which  will  yield  the  desired  information. 


CHAPTER   XXX. 

ANEMIA   OF   THE    LABYRINTH. 

i^tiology, — The  condition  may  depend  upon  profuse  gen- 
eral haemorrhage,  either  from  traumatism,  from  the  rupture 
of  an  aneurism,  from  uterine  haemorrhage  at  childbirth,  or 
may  be  the  result  of  simple  or  pernicious  anaemia.  The 
changes  which  take  place  are  due  to  the  impoverished  qual- 
ity of  the  blood  with  which  the  tissues  are  supplied,  the  lack 
of  nutrition  perverting  their  function  and  rendering  them 
less  capable  of  carrying  out  the  purposes  for  which  they 
were  designed. 

Symptomatology. — When  the  labyrinthine  structures  sufTer 
in  this  manner  we  find  the  power  of  audition  impaired,  par- 
ticularly for  sharp  sounds  and  musical  notes  of  a  high  j)itch. 
The  inyolvemcnt  of  the  auditory  function  is  similar  in  char- 
acter to  the  disturbance  which  is  noticed  in  every  part  of 
the  body.  When  nutrition  is  imperfect  no  organ  performs 
its  work  properly.  When  the  labyiinth  suffers  from  mal- 
nutrition the  patient  seems  listless  and  inattentive,  and  it 
requires  a  certain  eff(^rt  upon  his  part  to  hear  what  is  said. 
When  engaged  in  dialogue  the  hearing  may  not  seem  to  be 
much  affected,  but  when  several  are  speaking  at  once  he  is 
unable  to  follow  accurately  the  course  of  the  conversation. 
Subjective  noises  are  distressing,  and  are  usually  worse  upon 
lying  down,  depending  upon  the  adynamic  condition  of  the 
circulatory  system.  The  character  of  the  subjective  sounds 
is  usually  dull  and  low-pitched,  synchronous  with  cardiac 
pulsations,  and  is  apparently  identical  with  the  venous  bruit 
heard  over  the  great  vessels  of  the  neck  in  many  cases  of 
anaemia.  Attacks  of  vertigo  seldom  occur  spontaneously,  but 
result  from  apparently  slight  causes,  a  sudden  fright  being 
sufficient  many  times  to  induce  an  attack  of  syncope,  while 
the  same  condition  may  follow  an  insignificant  degree  of  pain 
or  some  slight  visceral  disturbance.  The  facies  of  the  patient 
is  somewhat  characteristic,  in  that  it  appears  dull,  abstracted, 

(541) 


542 


ANAEMIA   OF   THE    LABYRINTH. 


and  inattentive.  The  other  symptoms  presented  are  those 
common  to  simple  anemia,  and  bear  no  relation  to  the  por- 
tion of  the  body  now  under  discussion. 

Diagnosis. — The  pallor  of  the  skin  found  after  an  acute 
hsemorrhage,  or  the  peculiar  ashy-gray  color  met  with  in 
cases  of  simple  or  pernicious  ancemia,  should  always  attract 
attention.  The  variation  in  color  from  the  normal  standard 
is  frequently  better  observed  in  the  mucous  membranes  than 
in  the  cutaneous  surface  of  the  body.  These  may  appear 
blanched,  although  the  face  is  not  sufficiently  pallid  to  excite 
attention. 

A.  Physical  Examination. — In  cases  of  simple  anaemia,  ex- 
amination  with  the  otoscope  reveals  nothing  characteristic  of 
the  affection,  and,  unless  the  middle  ear  is  involved,  the  in- 
spection is  entirely  negative. 

B.  Functional  Examination. — The  lower  tone  limit  is  nor- 
mal ;  the  in)per  tone  limit  may  be  normal  or  reduced  ;  bone 
conduction  is  almost  always  reduced  to  a  marked  degree. 
The  perception  of  whispered  or  spoken  words  is  somewhat 
reduced,  although  it  may  be  nearly  normal.  It  will  be  no- 
ticed that  the  words  are  repeated  in  an  uncertain  manner  and 
slowly,  as  though  it  took  the  patient  some  time  to  compre- 
hend exactly  what  had  been  said.  This  is  due  to  inco-ordina- 
tion  in  the  receptive  mechanism,  the  different  portions  failing 
to  act  in  harmony.  Perception  for  high  sounds,  as  the  tick 
of  the  watch  or  the  click  of  the  acoumeter,  is  usually  more 
reduced  relatively  tiian  for  vocal  sounds. 

The  essential  points  upon  which  the  diagnosis  is  made  are: 

First,  the  absence  of  any  middle-ear  lesion. 

Second,  preservation  of  the  normal  tone  limits  (or  reduc- 
tion of  upper  limit). 

Third,  marked  impairment  of  bone  conduction. 

Fourth,  the  ana:."mic  appearance  of  the  patient. 

Prognosis. — In  acute  cases  depending  uj)on  haemorrhage, 
or  in  cases  of  simple  ancemia,  the  prognosis  is  alwavs  favor- 
able. In  pernicious  anaemia,  extravasations  within  the  nerve 
tissues  may  have  taken  place,  producing  permanent  structural 
changes. 

Treatment. — Certain  drugs,  such  as  iron  in  full  doses,  or 
arsenic,  cither  in  the  form  of  arsenious  acid.  Fowler's  solution 
or  Pierson's  solution,  etc.,  should  be  administered  for  the  pur- 
pose of  improving  the  quality  of  the  blood.     The  exhibition 


TREATMENT. 


543 


of  cardiac  stimulants  is  also  advisable  to  relieve  the  venous 
congestion  within  the  labyrinth.  Str}-chnine  fulfills  this  end, 
and  at  the  same  time  exerts  a  beneficial  effect  upon  the  nerv- 
ous tissues  themselves.  This  may  be  given  simultaneously 
with  ferruginous  preparations,  and  should  be  administered  in 
full  doses.  The  diet  should  be  liberal,  and  of  such  character 
as  to  improve  the  quality  of  the  blood.  The  exhibition  of 
alcohol  in  anv  quantitv  is  not  advisable,  excepting  in  acute 
cases,  or  possibly  to  the  extent  of  a  little  red  wine  at  dinner. 
Quinine  is  particularly  contraindicatcd  in  this  condition.  It 
is  true,  that  many  cases  improve  tcmporariU-  when  this  drug 
is  administered  ;  but  it  is  ecpiallv  true  that  thev  almost  invari- 
ably suffer  from  a  relapse,  and  that  the  svmptoms  are  more 
marked  than  those  which  characterized  the  {)rimarv  attack. 
The  temporary  engorgement  which  this  drug  induces  in  the 
labyrinthine  vessels  often  leads  to  permanent  changes  of  a 
hsemorrhagic  nature.  The  temporary  relief  gained  is  due  to 
the  increased  vascularitv  which  the  drug  causes,  and  not  to 
correction  of  the  condition  upon  which  the  symptoms  depend. 


CHAPTER   XXXI. 

IIYPER.EMIA   OF   THE    LABYRINTH. 

iEtiology. — An  increased  quantity  of  blood  within  the 
labyrinth  may  depend  either  upon  a  venous  stasis  from  me- 
chanical obstruction  to  the  return  current,  or  upon  an  in- 
creased quantity  of  arterial  blood  conveyed  to  the  jiart.  The 
condition  is  prone  to  occur  in  individuals  of  a  full  habit,  and 
particularly  in  those  who  are  the  victims  of  a  gouty  or  rheu- 
matic diathesis.  Those  whose  vocation  in  life  demands  con- 
siderable physical  activity  or  exposure  to  inclement  weather 
are  frequently  victims  of  this  condition.  Sudden  physical  ex- 
ertion is  productive  of  these  circulatory  changes,  especially  in 
athletes.  Overindulgence  in  alcohol,  by  increasing  the  force  of 
cardiac  systole,  leads  to  distention  of  the  labyrinthine  vessels. 
Rigidity  in  the  arterial  system,  by  diminishing  the  elasticity 
of  the  vessels,  increases  relatively  the  pressure  within  the  ar- 
teries. Sudden  diminution  in  atmospheric  pressure,  as  when 
one  ascends  to  a  great  height,  subjects  the  efferent  vessels  to 
the  full  force  of  the  cardiac  svstole,  and  hence  augments  the 
blood  passing  through  them.  The  prolonged  action  of  any 
one  sound  also  produces  hyperasmia,  either  niechanicallv  or 
from  over-stimulation,  as  is  observed  in  telephone  operatives, 
boiler-makers,  etc.  Condensation  of  the  air  in  the  meatus, 
from  a  blow  on  the  car  or  from  an  ex])losion,  forces  the 
stapes  suddcnlv  inward  to  an  abnormal  distance,  and  may 
cause  hyperccmia  of  the  labyrinth.  It  is  probable  that  cases 
of  mild  labyrinthine  concussion  are  of  this  nature. 

Among  those  causes  which  lead  to  a  venous  stasis  we  may 
enumerate  mechanical  obstruction  to  the  great  vessels  of  the 
neck,  such  as  pressure  from  a  tumor  or  the  sudden  lowering 
of  the  head,  the  venous  flow  being  then  retarded  by  the  force 
of  gravitation.  A  severe  attack  of  coughing,  by  increasing 
the  pressure  within  the  thorax,  temporarily  obstructs  the  pas- 
sage of  the   blood  into  the  right  auricle  and  dams  back  the 

(544) 


PATHOLOGY— SYMPTOMATOLOGY. 


545 


entire  venous  circulation.  Efforts  at  sneezing,  blowing  the 
nose,  etc.,  exert  the  same  influence. 

Pathology. — The  overdistention  of  the  blood  vessels  pro- 
duces but  few  changes  so  long  as  their  walls  are  in  a  state  of 
perfect  health  ;  when  continued  for  a  long  time,  localized  dila- 
tation takes  place,  causing  an  irregularity  in  the  blood  supply. 
Where  the  pressure  changes  are  sudden,  or  where  the  walls 
of  the  vessels  are  diseased,  they  may  rupture  and  produce 
apoplectic  changes.  A  venous  hypera^mia  is  more  prone  to 
become  permanent  on  account  of  the  tenuity  of  the  vessel 
walls.  The  labyrinthine  veins  are  to  a  great  extent  inclosed 
in  bony  channels,  for  the  purpose  of  avoiding  this  condition. 
Their  exposed  portions,  however,  suffer  when  an  obstruction 
to  the  venous  circulation  persists  for  a  considerable  period  ; 
the  vessels  become  tortuous  and  dilated,  and  there  is  a  transu- 
dation of  serum  into  the  labyrinthine  cavity.  Both  the  venous 
dilatation  and  the  serous  transudation  increase  labyrinthine 
pressure.  The  ultimate  changes  which  take  place  in  laby- 
rinthine apoplexy  do  not  differ  from  those  occurring  in  a 
similar  condition  in  other  parts  of  the  body.  The  effused 
blood  may  be  absorbed,  or  liie  affected  area  may  undergo 
disintegration. 

Symptomatology. — Such  an  augmentation  in  labyrinthine 
blood  supply  is  characterized  by  a  feeling  of  fullness  and  dis- 
tention in  the  head,  slight  giddiness  or  even  vertigo,  and  the 
presence  of  subjective  noises,  usually  of  high-pitched  char- 
acter. The  impairment  in  hearing  is  slight,  unless  the  vessel 
walls  suffer ;  then  it  may  be  profound  or  even  absolute,  the 
accompanying  giddiness  being  usually  severe,  and  the  tinnitus 
at  first  almost  unbearable.  Occurring  as  a  chronic  condition 
in  a  patient  of  full  habit,  we  find  these  symptoms  produced 
by  any  slight  exciting  cause,  such  as  fright,  rage,  sudden  ex- 
ertion, indigestion,  too  free  indulgence  in  stimulants,  etc. 

Diagnosis, — Physical  cxafniiiation  yields  no  information  be- 
yond showing  an  increased  vascularity  in  the  drum  mem- 
brane and  the  deeper  parts  of  the  canal,  causing  the  vessels 
to  be  more  distinctly  visible  than  normal.  Where  the  mem- 
brana  tympani  is  thin,  a  similar  condition  is  often  observed  in 
the  mucous  membrane  of  the  promontory. 

Fiinctioyial  Examination. — The  lower  tone  limit  is  exceed- 
ingly well  preserved  ;  the  upper  tone  limit  is  usually  reduced  ; 
bone  conduction  is  diminished,  and  the  power  of  audition  for 

37 


546 


HYPEREMIA    OF    THE    LABYRINTH. 


vocal  sounds  but  slightly  impaired.  For  sharp  sounds,  such 
as  those  of  the  acoumeter  or  watch,  a  condition  of  hyperacu- 
sis  may  be  present,  and  very  sharp  sounds  are  often  painful ; 
or  the  auditory  impression  may  persist  for  some  time  after 
the  source  of  sound  has  been  removed.  The  diagnosis  in 
chronic  cases  will  be  rendered  more  easy  if  attention  is  di- 
rected to  the  increased  vascularity  of  the  integument  of  the 
face  and  the  prominence  of  the  smaller  vessels  beneath  the 
skin,  which  is  a  fair  index  of  the  condition  of  the  circulatory 
system  within  the  labyrinth.  The  history  of  severe  physical 
exertion  or  of  a  gouty  or  rheumatic  diathesis  also  materially 
aid  us  in  arriving  at  a  correct  opinion. 

Prognosis. — Where  but  slight  impairment  of  hearing  is 
present,  we  may  hope,  in  recent  cases,  to  effect  an  absorption 
of  the  effused  serum  and  a  return  of  the  parts  to  a  condition 
of  integrity.  Where  the  condition  is  of  long  standing,  the 
outlook  is  more  unfavorable,  and  the  same  is  true  where  the 
chancres  are  of  hasmorrhaiiic  nature,  if  the  extravasation  is  of 
considerable  size.  In  chronic  cases  it  is  seldom  possible  to 
remove  the  condition  entirely,  although  much  relief  may  be 
secured  bv  carefully  regulating  the  habits  of  life. 

Treatment. — In  severe  cases  local  depletion  is  a  most  im- 
portant measure  to  be  adopted.  Considerable  blood  should 
be  abstracted  from  the  mastoid  region  by  means  of  the  wet 
cup.  General  bloodletting  is  permissible  when  the  attack  is 
of  unusual  severity.  Free  catharsis  should  be  effected  by  the 
administration  of  saline  purgatives,  and  free  diuresis  should 
also  be  obtained.  In  acute  cases  it  is  well  to  protect  the 
ear  from  the  action  of  sound  by  occluding  the  meatus  with 
cotton.  The  application  of  counterirritants  to  the  mastoid 
in  the  form  of  blisters  is  advocated  by  some,  but  is  of  more 
value  where  the  condition  has  continued  for  some  time  than 
immediately  after  an  exacerbation.  The  use  of  counterirri- 
tation  for  a  long  period  by  means  of  the  tincture  of  iodine 
applied  to  the  mastoid  region  is  of  some  value  in  the  older 
cases,  since  the  effusion  of  serum  within  the  labyrinthine 
chamber  implies  an  increase  in  pressure.  The  use  of  pilo- 
carpine is  of  benefit,  and  we  should  always  resort  to  it  if 
prompt  relief  does  not  follow  the  abstraction  of  blood.  In 
administering  this  drug,  it  is  convenient  to  employ  a  four- 
per-cent  solution,  as  in  this  way  the  dose  can  be  gradually 
increased  according-  to  indications.     The  initial  dose  for  an 


TREATMENT. 


547 


adult  is  from  one  sixth  to  one  eighth  of  a  grain  twice  or  three 
times  daily.  It  is  not  necessary  to  confine  the  patients  to  the 
house  to  the  extent  of  interfering  with  their  daily  vocations  in 
carrying  out  the  treatment.  It  is  only  necessary  that  for  about 
two  hours  after  each  dose  the  patient  should  guard  against 
draughts.  This  is  secured  if  one  dose  of  the  drug  is  taken 
immediately  upon  rising  in  the  morning,  when  the  effect  will 
have  passed  sufficiently  before  the  patient  is  obliged  to  go  out 
to  his  daily  work,  while  the  second  may  be  taken  upon  re- 
tiring. The  quantity  administered  should  be  just  sufficient 
to  increase  the  saliv^ary  or  cutaneous  secretions  slightlv,  but 
a  profound  efTect  is  undesirable.  The  patient  should  be  di- 
rected to  increase  the  dose,  so  that  the  physiological  action 
is  noticed  after  each  ingestion,  as  otherwise  tolerance  is  soon 
established  and  the  full  benefit  to  be  derived  is  not  obtained. 
It  is  also  of  great  value  in  instances  which  come  under  treat- 
ment only  after  a  considerable  interval  has  elapsed  since  an 
acute  attack,  the  reduction  in  pressure  frequently  being  fol- 
lowed by  relief.  This  is  probably  due  to  the  absorption  of 
the  effusion.  Iodide  of  potassium  internally,  in  doses  of  ten 
grains  three  or  four  times  daily,  may  be  given  for  the  same 
purpose,  but  is  usually  less  efficacious.  Next  to  the  treatment 
of  an  acute  attack,  the  most  important  measures  are  those  of 
a  prophylactic  nature.  Severe  and  sudden  physical  exertion 
should  be  enjoined.  Alcohol  should  be  interdicted,  and  the 
diet  should  be  so  regulated  as  to  diminish  the  general  pleth- 
ora. The  influence  of  a  gouty  or  rheumatic  taint  should 
never  be  forgotten,  and  the  prolonged  use  of  some  alkaline 
waters,  preferably  those  containing  lithium,  is  of  great  value. 
Attention  to  these  matters  not  only  tends  to  relieve  the 
chronic  congestion,  but  also  renders  the  patient  less  liable  to 
an  apoplectiform  lesion. 


CHAPTER   XXXII. 

LABYRINTHINE   H.-EMORRHAGE. 

iEtiology. — The  cause  of  a  rupture  of  the  walls  of  the 
labyrinthine  vessels,  with  an  extravasation  of  their  contents 
into  the  delicate  structures  which  the  cavity  contains,  may  be 
due  to  external  violence,  such  as  a  blow  upon  the  head  or  a 
fall  from  a  height,  or  the  sudden  action  of  a  loud  sound,  such 
as  an  explosion.  It  may  be  caused  by  manipulative  proce- 
dures directed  toward  the  relief  of  some  middle-ear  condition, ' 
as  a  forcible  inflation  by  means  of  the  catheter  or  Politzer 
bag,  or  severe  efforts  at  coughing  or  sneezing.  Mobilization 
or  removal  of  the  stapes  may  also  produce  the  condition 
under  discussion. 

Various  conditions  of  the  blood  itself — such  as  that  found 
in  the  hasmorrhagic  diathesis,  in  pernicious  anaemia,  and  in 
leucaemia,  or  fragility  of  the  walls  of  the  blood  vessels  met 
with  in  patients  of  advanced  years,  especially  those  who  are 
victims  of  a  gouty  diathesis — may  determine  the  same  result. 
The  same  accident  may  take  place  from  sudden  venous  con- 
gestion of  the  head,  as  produced  when  one  remains  with  the 
head  bent  forward  for  a  considerable  time,  or  when  the  ve- 
nous blood  is  prevented  from  entering  the  right  auricle  by 
holding  the  breath,  as  in  swimming  under  water  or  in  diving. 
Necessarily  the  condition  may  be  met  with  as  a  complicating 
lesion  of  cerebral  hyperasmia. 

Pathology. — The  effusion  of  blood  into  the  tissues  pro- 
duces the  same  changes  here  as  a  similar  lesion  in  other 
parts  of  the  body.  Where  the  haemorrhage  is  considerable, 
complete  disorganization  of  the  parts  may  take  place  from 
pressure,  and  a  return  to  the  normal  condition  becomes  im- 
possible even  if  the  effused  blood  is  subsequently  absorbed. 
In  other  cases  the  traumatism  is  not  so  great,  and  the  struc- 
tures pressed  upon  simply  suffer  from  a  mechanical  interfer- 
ence with  the  performance  of  their  function  without  under- 

(548) 


SYMPTOMATOLOGY— DIAGNOSIS. 


549 


going  degeneration  ;  this  is  always  produced  by  increased 
labyrinthine  pressure,  when  the  equilibrium  is  restored  only 
after  a  considerable  period.  The  clot  itself  may  remain  and 
become  organized,  or  may  be  completely  absorbed  or  undergo 
fibrous  or  calcareous  degeneration.  According  to  the  amount 
of  original  damage,  the  function  of  the  part  is  either  entirely 
destroyed  or  partially  or  completely  restored. 

Symptomatology. — When  a  labyrinthine  apoplexy  occurs, 
the  patient  is  usually  seized  with  giddiness  so  severe  as  to 
cause  him  to  fall  unless  he  obtains  some  artificial  support ;  at 
the  same  time  there  is  intense  nausea,  severe  tinnitus,  and  a 
very  high  degree  of  impairment  of  hearing,  or  absolute  deaf- 
ness. Unconsciousness  may  occur  if  the  attack  is  severe. 
When  it  follows  chronic  labyrinthine  hypera^mia,  certain  pre- 
monitory signs  often  manifest  themselves,  such  as  a  feeling  of 
fullness  and  distention  in  the  head,  a  throbbing  within  the 
ears,  the  cardiac  impulses  being  not  only  heard,  but  appar- 
ently felt  deep  in  the  head.  The  unsteadiness  of  gait  and 
impairment  of  hearing  usually  disappear  after  a  few  days  or 
weeks,  the  former  completely,  and  the  latter  to  a  marked 
degree,  although  the  hearing  does  not  become  normal.  The 
subjective  noises  persist,  and  may  even  increase  in  severity. 
Occasionall}'^  a  condition  of  hyperoesthesia  of  the  auditory 
nerve  follows,  certain  sounds  being  painful,  although  the  gen- 
eral auditory  power  is  greatly  impaired.  An  attack  of  this 
kind  renders  it  probable  that  subsequent  attacks  may  occur, 
especially  when  it  is  due  to  a  pathological  condition  of  the 
walls  of  the  blood  vessels. 

Diagnosis. — The  suddenness  of  the  attack,  the  severity  of 
the  vertigo  and  of  the  tinnitus,  the  extreme  nausea,  and  the 
sudden  and  marked  impairment  in  hearing  form  a  series  of 
symptoms  which  are  fairly  characteristic.  A  physical  exami- 
nation reveals  no  departure  from  the  normal  standard. 

Functional  examination,  in  addition  to  the  impairment  of 
hearing,  both  for  spoken  words  and  sharp  sounds,  will  show 
an  impairment  or  absence  of  sound  perception  through  the 
solid  media  of  the  skull.  The  limits  of  audition  may  be  vari- 
ously affected,  according  to  the  particular  site  of  the  lesion. 
Generally  the  lower  portion  of  the  labyrinth  is  involved,  in 
which  case  the  lower  tone  limit  remains  normal,  while  the 
upper  tone  limit  is  lowered  to  a  very  marked  degree.  This 
is  not  absolute,  for  if  the  haemorrhage  occurs  in  the  upper 


-:-0  LABYRINTHINE    HEMORRHAGE. 


5D 


part  of  the  cochlea  high  notes  may  t»e  the  only  ones  heard, 
while  the  low  notes  are  not  perceived  at  all. 

Prognosis. — When  the  haemorrhage  involves  but  a  very 
small  area,  spontaneous  recovery  may  take  place.  When  the 
lesion  is  extensive  it  is  probable  that  the  hearing  will  remain 
to  a  degree  impaired  whether  the  case  be  left  to  itself  or  sub- 
jected to  medication.  Improvement  may  be  hoped  for  in  the 
more  severe  cases  rather  than  in  those  where  the  extravasa- 
tion is  moderate.  The  prognosis  as  to  the  disappearance  of 
subjective  noises  is  less  favorable,  and  complete  relief  should 
never  be  promised.  The  disturbance  of  the  equilibrium  usu- 
ally disappears  completely. 

Treatment. — When  seen  immediately  after  the  attack,  local 
depletion  and  even  general  bloodletting  are  the  first  measures 
to  be  instituted.  A  wet  cup  to  the  mastoid  exerts  more  influ- 
ence upon  the  circulation  within  the  labyrinth  than  when  ap- 
plied in  any  other  location.  Free  purgation  should  then  be 
effected,  absolute  rest  in  bed  enjoined,  and  the  patient  should 
be  protected,  as  far  as  possible,  from  loud  noises,  and  forbid- 
den to  do  any  manual  work.  At  a  later  period  the  adminis- 
tration of  pilocarpine,  beginning  with  a  dose  of  one  sixth  of 
a  grain  three  times  daily  and  increasing  rapidlv  until  the 
physiological  effect  is  obtained,  often  causes  rapid  improve- 
ment by  reducing  labyrinthine  pressure.  The  general  condi- 
tion should  be  attended  to  in  the  same  manner  as  directed 
under  labyrinthine  hypercemia.  Iodide  of  potassium,  con- 
tinued for  six  or  eight  weeks,  seems  to  favor  the  absorption 
of  the  clot.  Counter-irritation  over  the  mastoid  process  bv 
means  of  iodine  or  vesicants  is  a  measure  to  be  employed  if 
convalescence  is  delayed.  Great  care  should  be  taken  to  warn 
the  patient  of  the  danger  of  a  similar  attack  at  some  future 
time. 


CHAPTER    XXXIII. 

LABYRINTHINE   EMBOLISM    AND   THROMBOSIS. 

iCtiology. — The  lodgment  in  one  of  the  smaller  vessels  of 
the  internal  ear  of  an  infectious  embolus  which  may  have 
been  thrown  into  the  circulation  as  the  result  of  a  patho- 
logical change  in  some  distant  organ,  or  the  development  of 
infectious  thrombi  within  the  venous  channels,  are  both  con- 
ditions met  with  in  rare  instances.  Embolism  is  specially 
rare,  although  it  has  occurred  in  cases  of  osteomyelitis,  and 
has  been  produced  artificially  in  the  lower  animals  by  the 
injection  of  some  of  the  low  vegetable  organisms  into  the 
blood.  A  thrombosis  occurs  more  frequently  as  the  result  of 
a  severe  suppurative  process  within  the  middle  ear,  such  as 
is  found  in  scarlatina,  diphtheria,  etc.  Here  the  blood  supply 
of  the  external  labvrinthine  wall  is  greatly  interfered  with, 
and  infection  takes  place  by  contiguitv  of  structure  through 
the  osseous  partition.  This  form  of  occlusion  of  the  venous 
channels  constitutes  the  labviinthine  lesion  in  manv  cases 
which  suffer  from  severe  purulent  otitis  during  one  of  the 
exanthemata. 

Pathology. — The  occlusion  of  an  arterial  twig  produces  at 
first  an  anaMiiia  of  the  area  which  it  supplies  ;  this  may  go  on 
to  disintegration  if  the  blood  supply  is  not  re-established,  but 
if  the  collateral  circulation  is  free  this  may  not  occur.  Throm- 
bosis of  a  venous  trunk  is  of  less  importance  except  where  it 
is  due  to  an  acute  infectious  process,  when  the  minute  septic 
foci  may  break  down  and  produce  severe  inflammation  of  the 
surrounding  parts. 

Symptomatology. — The  symptoms,  in  general,  resemble 
those  of  labyrinthine  haemorrhage,  except  that  they  are  less 
severe  ;  nausea  is  rare ;  vertigo  may  be  scarcely  noticeable, 
and  the  hearing  power  but  slightly  impaired.  The  sudden 
development  of  tinnitus  in  these  cases  is  probably  the  most 
constant  symptom.  It  is  probable  that  in  manv  instances 
where  tinnitus  alone  is  complained    of,   the   hearing  power 

(551) 


552         LABYRINTHINE    EMBOLISM   AND   THROMBOSIS. 

being  normal,  according  to  the  most  careful  tests,  a  small 
artery  or  vein  within  the  labyrinth  has  become  occluded, 
causing  sufficient  structural  change  to  produce  this  symptom 
without  otherwise  impairing  the  function  of  the  organ  to  a 
noticeable  extent.  From  the  intimate  relation  between  the 
venous  current  within  the  turbinated  bodies  and  that  of  the 
cochlea,  we  might  suppose  that  a  suppurative  inflammation  of 
one  of  the  accessory  sinuses,  such  as  the  ethmoid,  antrum,  or 
frontal  sinus,  would  be  particularly  prone  to  produce  this 
effect.  It  is  certainly  true  that  many  of  these  cases  suffer 
from  subjective  noises,  while  the  history  shows  that  the  onset 
was  sudden,  that  the  noise  has  remained  unchanged  for  a  con- 
siderable number  of  years,  or  has  perhaps  slightly  diminished, 
while  any  impairment  of  hearing  that  existed  in  the  early  stage 
of  the  affection  has  disappeared.  Here  the  inference,  that 
embolism  of  one  of  the  minute  vessels  has  been  the  lesion 
which  has  produced  the  symptom,  seems  logical. 

Prognosis. — Extensive  destruction  of  the  labyrinthine 
structures  frequently  follows  a  severe  suppurative  inflam- 
mation within  the  tympanum.  When  confined  to  a  small 
area  the  condition  usually  improves  as  age  advances,  and 
although  it  sometimes  disappears  spontaneously,  it  is  often 
unaffected  by  treatment.  The  lesion  does  not  tend  to  pro- 
gress, and  either  remains  quiescent  or  slowly  improves. 

Treatment. — The  first  indication  is  to  remove  the  cause, 
to  prevent  a  repetition  of  the  accident.  Measures  directed 
toward  the  labyrinth  itself  may  be  necessary  where  the  affect- 
ed area  is  extensive.  The  reduction  of  labyrinthine  pressure 
by  the  internal  administration  of  pilocarpine  and  subsequently 
of  iodide  of  potassium  is  practically  the  most  serviceable  plan 
of  treating  either  thrombosis  or  embolism.  For  the  constant 
tinnitus,  the  use  of  dilute  hydrobromic  acid  in  full  doses  will 
be  found  to  be  beneficial  not  only  in  relieving  the  symptom, 
but,  by  reducing  the  degree  of  hvpcrassthesia  of  the  recep- 
tive centres,  will  often  exert  a  certain  curative  effect.  The 
drug  should  be  given  in  doses  of  half  a  drachm  every  four 
hours,  or  more  frequently  if  necessary.  It  should  be  well 
diluted  with  water,  to  avoid  irritation  of  the  stomach.  Strych- 
nine in  full  doses  is  also  of  value  in  preventing  a  rapid  disor- 
ganization of  the  nerve  tissue  supplied  by  the  occluded  vessel 
both  by  its  specific  effect  upon  nerve  tissue  and  its  action  as 
a  cardiac  stimulant. 


CHAPTER   XXXIV. 

SPECIFIC   INFLAMMATION    OF   THE    LABYRINTH. 

iEtiology. — This  portion  of  the  receptive  mechanism  may 
be  the  seat  of  changes  due  to  hereditary  or  acquired  specific 
disease.  In  the  hereditary  cases  the  association  of  intersti- 
tial keratitis  is  so  frequent  as  to  point  to  the  dependence  of 
both  conditions  upon  the  same  cause.  When  it  occurs  as  the 
result  of  acquired  specific  disease,  it  is  usually  found  in  the 
tertiary  period,  although  very  rarely  it  is  met  with  in  the 
secondary  stage. 

Pathology. — The  changes  which  are  found  upon  post- 
mortem examination  are  of  a  chronic  inflammatory  character. 
The  lining  membrane  of  the  semicircular  canals  and  cochlea 
is  thickened,  narrowing  the  lumen  of  the  channels,  and  in 
some  instances  this  process  has  gone  on  to  the  development  of 
new  osseous  tissue,  causing  a  thickening  of  the  bony  walls  of 
the  passages.  Changes  characteristic  of  specific  disease  are 
present  in  the  blood  vessels;  they  consist  in  an  obliterating 
endarteritis,  narrowing  or  completely  occluding  the  vessel 
lumen.  From  this  the  parts  are  supplied  with  an  insufficient 
quantity  of  blood,  and  sufTer  from  impaired  nutrition,  which 
may  cause  necrosis  if  sufficiently  complete.  Where  the  nutri- 
tion is  seriously  interfered  with  the  parts  may  undergo  sof- 
tening, in  the  same  manner  as  occurs  in  gummata  in  various 
parts  of  the  body.  When  there  is  a  hypertrophic  process 
within  the  vestibule  the  newly  formed  bone  may  be  depos- 
ited about  the  oval  window,  producing  a  thickening  of  the 
foot  plate  of  the  stapes  or  a  synostosis  of  the  stapedio-vestibu- 
lar  articulation. 

Symptomatology. — The  occurrence  of  sudden  and  pro- 
found impairment  of  hearing,  with  the  development  of  sub- 
jective noises,  in  an  adult  apparently  in  perfect  health  and 
with  no  evidences  of  middle-ear  involvement,  should  always 
excite  suspicion  of  an  underlying  specific  cause.  In  the  he- 
reditary cases  the  impairment  in   hearing  may  be  steadily 

(553) 


554 


SPECIFIC    INFLAMMATION    OF    THE    LABYRINTH. 


progressive,  and  associated  with  ulceration  of  the  cornea,  as 
before  mentioned.  In  children  this  combination  of  symptoms 
is  particularly  liable  to  occur,  and,  unless  checked  by  treat- 
ment, progresses  rapidly,  so  that  the  hearing  power  becomes 
almost  completely  lost  in  a  short  time.  Disturbances  of  equi- 
librium are  not  common,  and  when  present  are  usually  slight. 
The  association  of  middle-ear  symptoms  may  be  confusing, 
and  mask  for  a  time  the  true  cause  of  the  attack. 

Diagnosis. — The  diagnosis  depends  upon  the  suddenness 
of  the  onset  and  the  profound  degree  of  impairment  in  hear- 
ing, while  vomiting  and  severe  vertigo  are  absent. 

If  physical  examination  reveals  the  middle  ear  normal,  the 
diagnosis  is  rendered  much  more  simple  ;  when  occurring  in 
the  secondary  stage,  an  associated  tubal  or  tubo-tympanic  in- 
flammation may  be  so  marked  as  to  lead  the  observer  to  sup- 
pose that  the  symptoms  arc  entirclv  due  to  the  condition  of 
the  middle  ear,  and  the  labvrinthinc  lesion  may  be  overlooked 
entirely.  Functional  examination,  however,  ordinarily  pre- 
vents this  error.  The  low  notes  are  fairly  well  heard  even  if 
the  middle  ear  is  involved,  the  lower  tone  limit  not  being 
elevated  proportionately  to  the  degree  of  impairment  of  hear- 
ing. The  upper  tone  limit  is  very  much  lowered,  and  sharp 
sounds  are  poorly  perceived,  the  impairment  in  this  direction 
being  more  marked  than  the  impairment  for  conversation. 
Bone  conduction  is  greatly  reduced  or  entirely  absent,  thus 
rendering  the  error  of  attributing  symptoms  to  an  affection 
of  the  middle  car  almost  impossible.  Other  signs  of  specific 
disease  should  also  be  sought  for.  In  children,  an  examination 
of  the  teeth  often  reveals  characteristic  "  Hutchinson  teeth," 
while  the  surface  of  the  body  ma}-  present  evidences  of  a  pre- 
vious specific  eruption.  The  examination  of  the  skin  is  of 
particular  importance  in  adults  where  the  disease  is  acquired 
rather  than  hereditary.  The  association  of  ulceration  of  the 
cornea  should  also  be  regarded  with  suspicion. 

Prognosis. — The  difficulty  in  determining  the  value  of  any 
form  of  medication  in  these  cases  depends  upon  the  fact  that 
the  disease  may  remain  quiescent  for  a  long  jieriod,  and  sud- 
denly be  excited  to  renewed  activity  by  some  intercurrent 
disease,  or  from  no  assignable  cause. 

We  therefore  can  not  alwavs  say  whether  the  cessation  of 
the  symptoms  occurs  spontaneously  or  is  the  result  of  treat- 
ment.    Medication  is  of  value  in  recent  cases  without  ques- 


TREATMENT.  555 

tion,  but  in  those  of  hereditary  origin  many  believe  that  the 
disease  can  not  be  checked  by  therapeutic  measures.  In  spite 
of  this,  no  case  should  be  considered  as  hopeless  without  hav- 
ing been  first  subjected  to  a  thorough  course  of  specific 
treatment. 

Treatment. — In  no  class  of  labyrinthine  cases  is  treatment 
more  gratifying  than  in  those  depending  upon  acquired  spe- 
cific disease.  Cases  due  to  a  hereditary  taint  respond  less 
promptly  to  treatment,  and  many  go  so  far  as  to  assert  that 
improvement  never  follows  the  exhibition  of  drugs.  In  this 
latter  class  of  cases  my  experience  is  so  limited  that  I  do  not 
feel  warranted  in  giving  a  personal  opinion  on  the  subject. 
In  the  acquired  cases,  however,  even  after  a  considerable 
time  has  elapsed  since  the  aural  symptoms  were  first  noticed, 
internal  medication  has  been  followed  by  gratifying  results. 
The  internal  administration  of  pilocarpine,  beginning  with 
doses  of  one  sixth  of  a  grain  and  increasing  the  dose  until  the 
physiological  effect  of  the  drug  is  obtained,  as  fully  described 
in  a  previous  chapter,  is  almost  invaiiably  followed  by  im- 
provement, both  as  regards  the  subjective  noises  and  the 
hearinof.  Its  action  is  much  more  marked  if,  in  connection 
with  it,  we  exhibit  the  iodide  of  potassium  in  full  doses,  begin- 
ning with  ten  grains  three  times  daily,  and  increasing  it  to 
two  or  four  drachms  daily.  In  addition — t)r  at  intervals, 
during  which  the  iodide  is  discontinued — small  doses  of  the 
bichloride  of  mercury  (one  thirty-second  to  one  sixteenth  of 
a  grain  three  times  dailv)  have  been  found  of  value.  If,  coin- 
cident with  the  labvrinthine  affection,  the  tympanum  is  also 
involved,  this  should  be  treated  as  a  simple  middle-car  inflam- 
mation, according  to  the  rules  already  laid  down,  the  Icjcal 
measures  employed  in  no  way  interfering  with  the  lesion 
within  the  labvrinth.  The  use  of  mercurial  ointment  about 
the  ear  is  probably  of  but  little  value,  better  results  being 
obtained  by  giving  a  mercurial  by  the  mouth.  In  recent 
cases,  where  it  is  desirable  to  obtain  the  constitutional  effect 
of  mercury  as  soon  as  possible,  the  process  of  general  inunc- 
tion, or  of  baths  of  mercurial  vapor,  may  be  used,  as  in  the 
treatment  of  any  manifestation  of  a  recent  specific  infection. 
Locallv,  however,  the  use  of  mercurial  ointment  is  of  no 
value.  In  the  hereditary  cases  the  treatment  should  be  di- 
rected to  an  improvement  of  the  general  health,  as  well  as 
toward  the  specific  taint.     In  addition  to  the  iodide  of  potas- 


556       SPECIFIC    INFLAMMATION    OF    THE    LABYRINTH. 

sium,  cod-liver  oil,  hypophosphites,  iron,  etc.,  should  be  given, 
and  the  diet  of  the  patient  should  be  as  liberal  as  possible. 
The  surroundings  of  the  patient  should  receive  attention,  and 
every  effort  should  be  made  to  keep  him  in  a  condition  which 
will  render  him  less  susceptible  to  the  action  of  the  heredi- 
tary taint. 

Strychnine  is  of  value  in  some  cases,  but  must  be  given  in 
full  doses.  For  an  adult  not  less  than  a  fifteenth  of  a  grain 
should  be  given  three  times  daily.  The  initial  dose  must,  of 
course,  be  small,  but  the  quantity  should  be  rapidly  increased. 
The  appearance  of  unpleasant  symptoms  will  be  an  indication 
for  reducing  the  dose.  As  already  stated,  the  results  will  be 
to  an  extent  uncertain. 


CHAPTER   XXXV. 

INFLAMMATION  OF  THE  LABYRINTH  SECONDARY  TO  CHRONIC 
SUPPURATIVE  AND  NONSUPPURATIVE  INFLAMMATION  OF 
THE   TYMPANUM. 

Pathology. — Where  the  tympanic  structures  have  been 
subjected  for  a  long  time  to  an  abnormal  degree  of  pressure 
from  an  adhesive  process  within  the  tympanum,  certain 
changes  take  place  within  the  bony  capsule,  both  as  the 
direct  result  of  mechanical  pressure  and  also  from  the  ab- 
lation of  function  which  this  increased  pressure  causes. 
Owing  to  the  augmentation  in  the  tension  within  the  laby- 
rinth, the  delicate  terminal  filaments  of  the  auditory  nerve  in 
the  lower  part  of  the  cochlea  and  in  the  vestibule  may  be 
completely  destroyed.  On  the  other  hand,  the  increased 
tension  may  prevent  the  conduction  of  aerial  vibrations  to 
these  nerve-end  organs,  and,  on  account  of  the  disease  in  the 
middle  ear,  they  may  undergo  atrophy  from  disuse,  so  that 
if  the  pressure  is  removed  and  the  normal  tension  within  the 
labyrinth  is  restored,  they  will  Jdc  no  longer  able  to  perform 
their  function.  The  inflammatory  process  within  the  tym- 
panic cavity  may  be  propagated  to  the  adjacent  labyrinthine 
parts  by  contiguity  of  structure.  This  is  especially  true  in 
those  cases  of  otitis  media  arising  from  the  deposit  of  new 
connective  tissue  in  the  niche  of  the  oval  or  round  window. 
By  extension,  the  parts  beyond  the  foot  plate  of  the  stapes 
undergo  similar  changes ;  the  vestibular  walls  become  thick- 
ened, the  process  at  first  resulting  in  thickening  of  the  peri- 
osteum, and  subsequently  in  the  deposit  of  new  osseous 
tissue,  thus  encroaching  upon  the  lumen  of  the  vestibule. 
Similar  changes  about  the  round  window  result  in  an  en- 
croachment upon  the  lumen  of  the  first  turn  of  the  cochlea. 
This  process  is  quite  characteristic  of  proliferous  otitis  media- 
It  is  also,  as  Politzer  has  recently  shown,  quite  commonly 
found  in  advanced  life,  and  constitutes  the  prominent  lesion 
in  the  presbycusis. 

(557) 


558 


INFLAMMATION    OF   THE    LABYRINTH. 


The  changes  which  take  place  within  the  labyrinth  in 
chronic  purulent  otitis  media  are  usually  less  marked  than  in 
the  nonsuppurative  form  of  the  affection.  Those  met  with  in 
residuary  cases,  where  the  purulent  inflammation  has  run  its 
course,  are  due  to  pressure  or  disuse,  or  to  both  combined. 
While  there  is  active  suppuration,  an  actual  infection  of  the 
labyrinthine  structures  may  take  place  through  the  fenestra 
ovalis  or  the  fenestra  rotunda,  leading  to  a  purulent  inflamma- 
tion of  the  labyrinth.  This  may  be  transmitted,  either  through 
the  blood  vessels  or  through  the  aquaeductus  vestibuli  or 
aquseductus  cochleae,  to  the  meninges,  and  cause  a  leptomenin- 
gitis.  In  the  labyrinth  such  a  purulent  inflammation  results 
in  a  disintegration  of  the  structures  involved.  This  would 
mean  complete  destruction  of  the  labyrinth  if  the  entire  re- 
gion were  affected.  Fortunately,  however,  such  an  inflamma- 
tion is  frequently  confined  to  the  immediate  neighborhood  of 
the  external  labyrinthine  wall,  and  its  destructive  effects  are 
limited  to  the  vestibular  structures  and  to  those  elements 
lying  in  the  first  turn  of  the  cochlea.  Meningitis  seldom 
occurs  by  infection  through  the  lymph  channels  of  the  inter- 
nal ear,  and  this  of  itself  argues  strongly  against  any  free 
anastomosis  between  the  vessels  of  the  middle  ear  and  those 
of  the  labyrinth  immediately  adjoining.  Suppuration  within 
the  tympanic  cavitv  mav  produce  changes  due  to  pressure 
alone,  infection  not  taking  place.  In  such  an  event  the  parts 
may  be  restored  to  their  normal  condition  by  treatment  of  the 
tympanic  affection,  and  will  then  resume  their  proper  function. 

In  addition  to  these  structural  changes,  recognizable  under 
the  microscope  in  pathological  specimens,  we  must  remember 
that  in  many  cases,  probably,  in  which  the  middle  ear  is  the 
seat  of  a  chronic  inflammatory  process,  the  labyrinthine  struc- 
tures in  the  immediate  vicinity  of  the  tympanum  become 
congested,  and  remain  in  this  condition  for  a  considerable 
period,  without  actual  tissue  metamorphosis.  The  vascular 
disturbances  consist  either  of  increase  in  the  arterial  sup- 
ply, or  a  diminution  of  the  venous  outflow,  augmenting  the 
labyrinthine  tension  and  giving  rise  to  symptoms,  although 
microscopic  specimens  would  reveal  no  structural  changes. 
We  are  warranted,  however,  in  the  supposition  that  these 
conditions  are  present  from  the  history  of  certain  cases. 

Symptomatology. — The  exact  line  of  demarcation  between 
symptoms  dependent  upon  middle-ear  or  labyrinthine  changes 


SYMPTOMATOLOGY— TINNITUS. 


559 


can  not  be  drawn.  All  symptoms  of  impairment  or  perver- 
sion of  function  must,  strictly  speaking,  be  relegated  to  the 
perceptive  tract,  and  it  is  diflficult  to  say  when  thev  are  pro- 
duced by  mechanical  irritation  simply,  from  alterations  in  the 
tension  of  the  conducting  apparatus,  and  when  certain  changes 
have  actually  taken  place  in  the  labyrinth  itself.  The  most 
constant  symptom  is  undoubtedly  the  presence  of  subjective 
noises.  In  the  early  stages  of  a  nonsuppurative  otitis  media 
the  persistence  of  tinnitus  should  be  looked  upon  as  an  indi- 
cation that  the  labyrinth  is  at  least  congested,  and,  unless 
prompt  measures  are  taken  for  the  relief  of  the  condition, 
must  soon  become  the  seat  of  organic  changes.  The  sub- 
jective noises  vary  in  character  and  in  intcnsitv.  At  first  they 
are  intermittent,  occurring  chicflv  when  the  recumbent  posi- 
tion is  assumed,  as  this  posture  favors  a  determination  of 
blood  to  the  head.  In  neurotic  individuals  any  severe  nerv- 
ous strain,  or  even  physical  exertion,  will  serve  to  increase 
them.  The  same  is  true  of  impairment  of  the  general  health, 
or  asthenia  following  a  severe  illness. 

When  these  noises  are  intermittent,  and  due  chieflv  to 
congestion,  they  are  frequently  svnchronous  with  cardiac 
pulsations;  but  as  the  disease  advances  this  pulsating  tin- 
nitus diminishes,  and  is  replaced  by  a  constant  high-pitched 
musical  sound  as  the  lower  portion  of  the  receptive  tract 
becomes  involved.  These  patients  also  complain  that,  in  ad- 
dition to  this  high-pitched  musical  note,  they  hear  at  in-egu- 
lar  intervals  loud,  low-pitched  sounds,  variously  described 
as  rumbling,  roaring,  thumping,  or  booming  noises.  We 
may  surmise  that  these  are  produced  by  changes  w.ithin  the 
cristas  and  acustic^e.  In  those  cases  where  the  tympanic 
process  is  confined  chieflv  to  the  region  of  the  oval  or 
round  windows  the  interference  with  sound  transmission 
may  be  so  slight  as  to  occasion  very  little  impairment  in  the 
hearing,  and  the  subjective  noises  mav  constitute  the  sole 
symptom  of  which  the  patient  complains,  the  labyrinthine 
structures  being  involved  at  a  very  early  period.  As  the 
process  advances,  the  subjective  noises  change  their  charac- 
ter, becoming  of  lower  pitch,  and  finally  thev  mav  disappear 
entirely,  owing  to  a  complete  destruction  of  the  nerve  fila- 
ments. This  same  general  train  of  symptoms  is  occasionally 
met  with  in  cases  of  chronic  suppurative  inflammation  where 
the  process  is  still  active,  or  in  residuary  cases,  but  is  always 


560  INFLAMMATION   OF   THE    LABYRINTH. 

present  to  a  much  less  degree  than  in  the  instances  of  hyper- 
plastic otitis  media.  The  reason  for  this  is  probably  twofold, 
the  first  being  that  the  process  within  the  tympanum  has 
been  followed  by  destruction  of  portions  of  the  conducting 
mechanism,  and  increased  labyrinthine  tension  may  be  pres- 
ent to  only  a  very  slight  degree.  As  a  second  reason,  we 
should  remember  that  the  inflammatory  process  within  the 
labyrinth  itself  is  not  of  such  a  character  as  to  lead  to  the 
deposit  of  new  tissue,  but  to  an  increase  in  the  amount  of 
perilymph.  This  increase  takes  place  slowly,  and  is  com- 
pensated for  by  the  passage  of  the  fluid  outward  into  the 
endocranial  lymphatic  spaces. 

In  addition  to  the  tinnitus,  disturbance  of  the  equilibrium 
is  frequently  complained  of.  This  points  to  the  invasion  of 
that  portion  of  the  labyrmth  in  immediate  relation  with  the 
semicircular  canals,  as  well  as  involvement  of  the  canals 
themselves.  The  vertigo  may  be  constant  or  intermittent,  oc- 
curring only  upon  some  sudden  change  in  the  position  either 
of  the  entire  body  or  of  the  head,  or  it  may  be  due  to  visceral 
disturbances.  Sudden  changes  in  intratympanic  pressure  do 
not  under  normal  conditions  cause  vertigo;  but  when  the  ap- 
paratus which  presides  over  the  static  condition  of  the  body 
is  in  unstable  equilibrium,  even  a  slight  disturbance  may  cause 
giddiness.  A  sudden  closure  of  the  Eustachian  tube — the  re- 
sult of  an  acute  rhinitis  or  naso-pharyngitis — or  a  powerful 
effort  at  blowing  the  nose,  or  a  severe  fit  of  coughing,  may 
so  alter  the  pressure  as  to  bring  on  an  attack  of  dizziness. 
Any  process  which  suddenly  increases  the  blood  pressure 
within  the  labyrinth  is  capable  of  bringing  on  vertigo.  Here 
we  may  mention'  violent  exercise,  suddenly  lowering  the 
head  in  stooping,  intense  mental  excitement,  as  either  rage  or 
grief,  etc. 

The  vertigo  seldom  persists,  but  disappears  in  late  stages 
of  the  disease.  The  impairment  of  hearing  varies  greatly  in 
degree,  and  the  subjective  symptoms  may  cause  the  patient 
to  seek  relief  before  he  has  noticed  anv  change  in  the  power 
of  audition.  The  reason  of  this  is  that  the  perception  of 
the  highest  notes  of  the  musical  scale  is  of  little  use  in  the 
ordinary  vocations  of  life,  and  conversation  may  be  perceived 
without  difficulty,  although  the  upper  tone  limit  is  consid- 
erably lowered. 

The  clinical  history  detailed  above  presupposes  the  in- 


INVOLVEMENT   OF   OPPOSITE   EAR.  561 

volvement  of  but  one  ear.  Sooner  or  later  the  org^an  of  the 
opposite  side  becomes  involved,  and  then  the  impairment  in 
function  becomes  decidedl}'  noticeable  and  increases  with 
great  rapidity.  The  balance  of  evidence  at  present  seems  to 
favor  the  view  that  the  involvement  of  the  ear  of  the  oppo- 
site side  is  due  to  an  extension  of  the  process  from  the  one 
first  attacked,  rather  than  that  it  is  dependent  upon  an  inflam- 
matory process  similar  in  character  but  of  primary  origin. 
This  extension  can  readily  be  understood  if  we  remember 
the  crossing  of  the  fibres  of  the  eighth  nerve  in  the  medulla, 
through  which  the  cortical  auditory  region  receives  fibres 
from  the  lab3^rinth  of  either  side,  but  chiefly  from  the  oppo- 
site labyrinth.  An  involvement  of  this  principal  terminal  ap- 
paratus would  cause  degenerative  changes  to  take  place  in 
the  centre  itself.  These,  in  turn,  would  excite  certain  dis- 
turbances in  that  portion  of  the  cortex  deriving  its  supply 
from  the  nerve  of  the  side  corresponding  to  the  cortical  area, 
thus  ablating  the  function  of  this  portion  of  the  cochlea  of 
this  side.  Clinical  observation  shows  that  in  a  large  propor- 
tion of  cases  of  hyperplastic  otitis  media,  with  comj)licating 
labyrinthine  involvement,  the  labyrinthine  changes  in  the  ear 
last  affected  are  more  extensive  than  those  in  the  organ  first 
involved.  Of  twenty-six  of  mv  own  cases,  sixteen  exhibited 
this  condition.*  The  t3-mpanum  also  becomes  involved  sec- 
ondarily, but  to  a  much  less  extent  than  the  labvrinth,  and 
the  impairment  of  function  seems  to  be  due  chiefly  to  the 
labyrinthine  changes.  These  alterations  occur  so  rapidly 
that  the  patient  not  infrequently  presents  with  the  history 
that  the  ear  first  involved  is  at  present  of  the  most  use  to 
him.  It  is  of  great  importance  to  obtain  a  correct  history 
of  the  case,  and  we  should  learn  definitely,  if  possible,  in 
which  ear  the  impairment  of  hearing  began,  and  at  what 
period.  Unless  great  care  is  taken  to  obtain  these  data  a 
grave  error  may  be  made. 

After  the  terminal  filaments  of  the  auditory  nerve  have 
been  the  seat  of  changes  for  a  considerable  period,  the  sub- 
jective noises,  which  were  at  first  distressing,  become  less 
severe,  owing  to  the  complete  ablation  of  function  of  this  por- 
tion of  the  cochlea.  The  spontaneous  cessation  of  tinnitus  in 
one  ear  furnishes  a  clew  to  the  information  desired,  and  it  is 


New  York  Eye  and  Ear  Infirmary  Reports,  1894  vol.  ii,  p.  62. 
33 


562 


INFLAMMATION    OF    THE    LABYRINTH. 


usually  the  case  that  the  organ  first  involved  causes  less  dis- 
tress from  this  cause  than  does  its  fellow.  Where  the  tym- 
panic process  is  marked  in  the  ear  last  involved,  the  symp- 
toms differ  in  that  the  impairment  of  hearing  is  usually  about 
equal  upon  the  two  sides,  or  audition  is  perhaps  slightly  bet- 
ter upon  the  side  last  involved. 

Diagnosis. — A.  Physical  Exaniination. — Upon  inspecting  the 
ear  we  have  presented  a  picture  of  chronic  catarrhal  inflam- 
mation, or  the  various  changes  resulting  from  a  suppurative 
process.  In  the  nonsuppurative  variety  the  parts  may  vary 
but  little  from  the  normal  standard,  as  far  as  appearances  are 
concerned,  the  reason  being  that  the  pathological  changes 
take  place  mostly  at  the  oval  and  round  windows.  The  more 
external  parts  of  the  conducting  mechanism  may  be  but  little 
affected.  The  color,  density,  lustre,  and  position  of  the  drum 
membrane  may  be  within  normal  limits,  provided  the  changes 
have  been  hyperplastic  from  the  start.  In  those  cases  sec- 
ondarv  to  a  hvpertrophic  process  the  position  of  the  drum 
membrane  is  usually  abnormal ;  it  is  commonly  retracted  to  a 
greater  or  less  degree,  and  presents  variations  in  densitv  in 
different  areas,  while  the  breadth  of  the  malleus  handle  is 
either  orreater  or  less  than  under  normal  conditions,  from  a 
rotation  of  this  ossicle  upon  its  long  axis.  This  has  been 
fully  described  in  a  previous  chapter. 

Where  the  internal  ear  is  involved  as  the  sequel  to  a  sup- 
purative inflammation  which  has  run  its  course,  the  appear- 
ances vary  according  to  the  amount  of  destruction  which  has 
taken  place.  The  posterosuperior  quadrant  is  the  region  to 
be  particularly  inspected  as  throwing  light  upon  the  probable 
cause  of  the  involvement  of  the  perceptive  portion  of  the 
auditory  svstem.  We  mav  find  the  stapes  forced  deeply  into 
the  oval  niche  and  fixed  by  adhesions,  which  bind  the  crura 
firmly  to  the  borders  of  the  pelvis  ovalis.  or  a  tense  posteiior 
fold  may  cause  a  similar  condition.  The  niche  of  the  round 
window  is  quite  frequently  in  view,  and  should  always  be 
examined  for  adhesions,  as  these  may  play  an  important  part 
in  the  production  of  the  symptoms.  Where  the  stapes  has 
become  separated  from  the  incus,  during  the  course  of  a  sup- 
purative infiammation,  the  condition  of  the  other  ossicula  may 
be  practically  disregarded,  since  the  structures  within  the  pel- 
vis ovalis  and  niche  of  the  round  window  alone  affect  the  con- 
dition of  the  lab3-rinth.      In   the   nonsuppurative  cases  it  is 


FUNCTIONAL    EXAMINATION.  563 

important  to  determine  whether  the  middle-ear  affection  has 
become  quiescent,  or  whether  it  is  still  active  and  progress- 
ive. To  decide  this  definitely  is  often  impossible  ;  although 
hyperaemia  at  the  inner  extremity  of  the  bony  meatus,  close 
to  the  tympanic  ring,  may  usually  be  looked  upon  as  an  evi- 
dence that  the  tympanic  affection  is  still  active,  while,  if  the 
parts  are  pale,  the  process  is  probably  quiescent,  and  the  laby- 
rinthine changes  are  not  liable  to  be  augmented  bv  the  fur- 
ther progress  of  the  middle-ear  lesion. 

B.  Functional  Examination. — The  hearing  is  impaired  both 
for  sharp  sounds  and  for  w'hispered  or  spoken  words.  It 
may  be  roughly  stated  that  where  the  labyrinthine  involve- 
ment is  extensive,  sharp  noises  are  relatively  more  poorly 
heard  than  speech,  the  converse  being  true  when  a  tympanic 
affection  predominates. 

The  lower  tone  limit  is  elevated,  the  upper  tone  limit  re- 
duced, the  degree  varying  with  the  extent  of  the  labvrinthine 
lesion;  bone  conduction  is  decidedly  diminished  or  may  be 
entirely  absent,  Rinne's  experiment  will  be  negative  for  the 
lower  notes  of  the  scale,  becoming  positive  as  the  test  is  made 
with  the  higher  forks.  It  is  now  important  to  determine  in 
anv  given  case  how  much  of  the  impairment  depends  upon 
the  condition  within  the  tympanum  and  how  much  upon  the 
secondary  labvrinthine  changes,  if  we  compare  the  degree 
of  defective  audition  for  whispered  or  spoken  words  with  the 
point  in  the  musical  scale  at  which  Rinne's  experiment  be- 
comes positive,  we  have  an  estimate  of  the  relative  amount 
of  middle -ear  and  lab3'rinthine  involvement.  Where  this 
point  lies  high  in  the  musical  scale  in  cases  where  the  func- 
tion is  impaired  to  a  marked  degree,  we  are  warranted  in 
the  conclusion  that  the  chief  trouble  lies  within  the  tympa- 
num. Confirmatory  of  this  we  find  the  upper  tone  limit  but 
slightly  lowered,  and  bone  conduction  either  normal  or  but 
little  impaired.  Naturally  the  age  of  the  patient  must  be 
taken  into  account  in  drawing  these  deductions.  If,  on  the 
other  hand,  we  have  to  deal  with  a  patient  who  hears  the 
whisper  only  when  the  words  are  -repeated  close  to  the  ear, 
and  Rinne's  experiment  becomes  positive  in  the  lower  portion 
of  the  scale,  the  tympanum  is  not  the  part  most  involved.  In 
such  an  instance  we  should  expect  to  find  a  marked  lowering 
of  the  upper  tone  limit,  and  poor  bone  conduction.  In  de- 
ciding this  question,  it  is  well  to  make  several  exam.inations, 


564 


INFLAMMATION   OF   THE    LABYRINTH. 


since  any  sudden  disturbance  within  the  tympanum  causing  a 
temporary  increase  in  labyrinthine  pressure  might  mislead  us. 
The  results  obtained  from  functional  examination  conducted 
in  this  manner,  taken  in  connection  with  the  history  of  the 
case,  the  age  of  the  patient,  etc.,  will  seldom  fail  to  render 
the  diagnosis  clear.  Certain  symptoms  of  which  the  patient 
complains,  such  as  the  cessation  of  subjective  noises,  the 
presence  or  absence  of  paracusis  Willisii,  evidences  of  audi- 
tory fatigue,  and  marked  variations  in  the  hearing  power 
dependent  upon  meteorological  changes,  are  also  of  value. 
With  reference  to  this  last  symptom,  I  feel  certain  that  vari- 
ations following  changes  in  the  weather  are  quite  as  charac- 
teristic of  an  affection  of  the  cochlea  as  of  one  of  the  middle 
ear.  This  point  has  been  sufficiently  considered  in  a  previ- 
ous section. 

The  reaction  of  the  auditory  nerve  to  electrical  stimuli  is 
of  diagnostic  value.  If  a  hyperassthetic  condition  is  present, 
this  denotes  activity  or  progression  of  the  disease,  but  does 
not  locate  it  definitely,  since  this  hypera^sthesia  may  depend 
upon  the  excitation  of  the  terminal  filaments  bv  a  progressive 
tympanic  inflammation,  or  it  may  be  the  result  of  an  active 
process  within  the  labyrinth.  The  inspection  of  the  parts 
will  usually  enable  the  surgeon  to  decide  whether  the  tym- 
panic inflammation  is  active  or  quiescent,  and  in  this  way  to 
determine  the  cause  of  the  hypera^sthcsia. 

It  should  be  the  rule  to  investigate  both  ears  with  equal 
care,  otherwise  incipient  involvement  may  be  overlooked, 
Galvanic  hyperassthesia  upon  one  side  may  depend  upon  in- 
flammation of  the  opposite  tympanum. 

Prognosis. — Any  implication  of  the  peripheral  filamenta 
of  the  auditorv  nerve,  secondary  to  changes  within  the  mid- 
dle ear,  constitutes  in  every  case  a  grave  condition.  The  ulti- 
mate result  must  be  considered  both  with  reference  to  the 
further  progress  of  the  disease  and  to  correcting  the  effects 
already  produced.  In  the  cases  following  a  destructive  in. 
flammation  within  the  tvmpanum,  a  steady  advance  of  the 
symptoms  is  seldom  looked  for.  We  occasionally  meet  with 
instances  in  which  a  preceding  suppurative  otitis  media  af- 
fecting one  side  onlv,  produces  late  in  life  certain  disturbances 
in  the  organ  upon  the  opposite  side.  When  this  occurs  the 
prognosis  as  regards  the  healthy  ear  is  of  chief  moment,  the 
other  organ  having  been  practically  useless  for  a  long  time. 


PROGNOSIS— TREATMENT.  565 

If  unchecked  b}'  proper  measures  a  steady  advance  must  be 
expected.  In  nonsuppurative  cases  the  involvement  of  one 
ear  is  followed  sooner  or  later  bv  a  corresponding  process 
upon  the  opposite  side.  In  unilateral  cases,  if  we  can  do 
nothing  to  improve  the  condition  of  the  affected  organ,  the 
earlv  adoption  of  measures  directed  to  the  removal  of  its  effect 
upon  the  opposite  ear  may  stop  the  progress  completely.  In 
bilateral  cases  we  may  usually  assume  that  where  the  tvm- 
panic  disease  predominates  upon  the  side  first  involved,  its 
proper  treatment  will  not  only  improve  the  function  of  both 
organs,  but  will  stop  the  progress  of  the  disease  completely. 
With  regard  to  the  progress  of  the  labvrinthinc  lesion  in  the 
organ  first  affected,  this,  almost  without  exception,  advances, 
unless  checked  artificially,  until  the  function  of  the  car  is  en- 
tirely ablated.  The  probable  result  of  treatment  will  depend 
upon  the  extent  to  which  the  process  has  advanced  before  the 
case  comes  under  observation.  Where  we  judge  that  a  com- 
paratively small  portion  of  the  cochlea  is  involved,  we  may 
hope  to  restore  the  function  to  a  great  degree.  If  extensive 
changes  have  taken  place,  complete  retrogression  must  not 
be  hoped  for.  But  a  considerable  amelioration  of  the  symp- 
toms may  occur  even  in  cases  of  long  standing.  In  general, 
those  cases  dependent  upon  suppurative  disease  are  much 
more  favorable  than  those  where  connective-tissue  hyperplasia 
has  occurred  primarily. 

Treatment. —  First  of  all  wc  must  remove  any  condition 
within  the  tympanum  which  might  cause  labyrinthine 
chancres.  In  other  words,  treatment  directed  to  the  middle 
ear  is  not  contraindicated  in  instances  of  mixed  disease,  ex- 
cept in  cases  where  the  labyrinthine  condition  is  the  most 
prominent  feature  and  has  existed  for  so  long  a  .time  as  to 
render  its  relief  impossible  even  if  the  tympanic  lesion  could 
be  overcome.  Adhesions  must  be  absorbed  or  divided  ac- 
cording to  their  density.  In  suppurative  cases  surgical 
measures  are  practically  the  only  ones  at  our  disposal,  and 
the  stapes  and  the  membrane  about  the  round  window  must 
be  relieved  of  any  increased  tension.  Tense  bands  must  be 
divided  according  to  the  principles  of  aseptic  surgery,  and 
this  process  continued  until  the  niche  of  the  oval  and  round 
window  is  perfectly  free.  In  the  nonsuppurative  cases  sur- 
gical measures  may  be  called  into  requisition,  although  here 
with  less  promise  of  success  than  in  the  preceding  instances. 


566 


INFLAMMATION    OF    THE    LABYRINTH. 


This  subject  has  been  thoroughly  dealt  with  under  Middle 
Ear  Operations,  and  need  not  be  repeated.  The  procedures 
are  to  be  instituted  both  for  the  organ  first  affected  and  for 
its  fellow  of  the  opposite  side.  Concerning  the  administra- 
tion of  drugs,  pilocarpine  seems  to  be  the  remedy  best 
adapted  to  these  cases.  It  is  to  be  administered  preferably 
by  the  mouth,  beginning  with  doses  of  one  eighth  to  one 
sixth  of  a  grain  twice  or  three  times  daily,  the  amount  to  be 
increased  according  to  the  toleration  of  the  patient.  If  bene- 
fit is  to  be  obtained,  the  constitutional  effects  of  the  drug  must 
be  produced,  and  its  administration  continued  for  a  period  of 
two  months,  and  in  many  cases  longer.  No  improvement 
should  be  expected  under  two  weeks  or  a  month,  and  it  is 
frequently  delayed  beyond  this  time. 

Where  one  ear  has  been  considered  useless  by  the  patient 
for  many  years,  a  condition  of  torpidity  of  the  auditory  nerve 
and  corresponding  centres  manifests  itself.  This  is  best  com- 
bated by  the  administration  of  strychnine  in  full  doses,  begin- 
ning with  one  fortieth  of  a  grain  three  times  daily,  increasing 
to  one  twentieth  or  one  fifteenth  if  the  drug  is  well  borne. 
This  drug  may  be  advantageously  administered  in  connection 
with  pilocarpine. 

Where  there  is  a  history  of  either  hereditary  or  acquired 
specific  disease  the  iodides  in  full  doses  frecpientlv  j)roduce 
remarkable  results.  Much  has  been  wiitten  of  late  upon 
the  treatment  of  these  cases  by  sonorous  vibrations  by  means 
of  the  phonograph  or  some  similar  instrument.  This  form  of 
treatment  is  by  no  means  new,  the  idea  being  mentioned  by 
Toynbee,*  who  reports  a  case  of  great  improvement  follow- 
ing the  use  of  the  conversation  tube  for  a  considerable  period 
of  time.  In  this  instance  the  human  voice  was  the  ajrent  em- 
ployed.  Later,  tuning  forks  were  used  for  the  same  purpose, 
the  fork  being  maintained  in  vibration  before  the  patient's  ear 
for  a  certain  length  of  time,  and  effecting  both  massage  of 
the  rigid  ossicular  articulations  and  stimulation  of  the  audi- 
tory nerve  itself.  The  employment  of  the  phonograph,  vibro- 
phone,  vibrometer  and  similar  devices  for  effecting  the  same 
result,  is  merely  an  application  of  this  |)rinciple,  the  apparatus 
used  being  of  little  importance. 

There  is  evidence  to  show  that  by  following  this  plan  sub- 

*  Diseases  of  the  Ear.  p.  433. 


TREATMENT— GENERAL.  567 

jective  noises  are  reduced  in  intensity  and  the  hearin*^  in  cer- 
tain cases  improved.  For  a  considerable  period  of  time  I  have 
advised  the  use  of  some  simple  form  of  conversation  tube,  the 
patient  being  read  to  by  an  attendant  for  perhaps  ten  or  fif- 
teen minutes  twice  daily,  in  a  tone  of  voice  that  can  be  easily 
perceived.  Any  words  which  arc  not  clearly  heard  should 
be  repeated  distinctlv  at  least  ten  times.  In  this  way  the 
torpidity  of  the  receptive  centre  is  overcome  and  the  patient 
learns  to  interpret  correctly  the  words  which  he  hears,  al- 
though they  may  not  be  perfectly  heard.  The  process  is 
exactlv  similar  to  that  of  a  child  learning  to  talk,  or  of  an 
adult  learning  a  foreign  language,  the  sensorium  being 
really  educated  so  as  to  correctly  interpret  the  perverted 
auditory  stimuli. 

The  relief  of  subjective  noises  seldom  forms  a  prominent 
indication  for  treatment  in  cases  of  advanced  labyrinthine 
disease.  Where  these  are  distressing,  however,  a  period  of 
temporarv  relief  may  usually  be  obtained  by  the  administra- 
tion of  large  doses  of  hydrobromic  acid,  and  it  is  wise  in  all 
cases  to  cmplov  this  drug  when  the  noises  first  appear.  If 
thev  are  allowed  to  continue,  the  higher  centres  become  so 
irritated  that  the  removal  of  the  primary  cause  of  the  disease 
mav  fail  to  relieve  this  distressing  symptom  completely.  Con- 
cerning the  effect  of  climate  upon  the  progress  of  the  afTec- 
tion  but  little  is  actually  known,  and  I  have  never  considered 
the  matter  of  climate  of  sufficient  importance  to  insist  upon  a 
change  of  residence  for  the  aural  affection  alone.  Of  much 
more  importance  is  the  general  condition  of  the  patient. 
Overfatigue,  mental  strain,  irregularities  in  diet,  or  the  ex- 
cessive use  of  stimulants  must  be  positively  interdicted.  The 
employment,  except  when  it  is  imperative,  of  any  drugs — 
such  as  quinine  or  salicylic  acid — which  are  known  to  cause 
an  intense  congestion  of  the  labyrinth,  must  also  be  forbidden, 
since  their  ingestion,  even  in  small  doses,  may  excite  the  pro- 
cess to  renewed  activity.  Diathetic  conditions  must  be  con- 
trolled, particularly  those  of  a  gouty  or  rheumatic  character. 

Treatment  of  the  upper  air  passages,  in  the  hope  of  im- 
proving the  aural  condition,  is  useless  when  these  measures 
are  undertaken  for  this  purpose  alone.  It  is  of  great  impor- 
tance, however,  that  deviations  from  the  normal  standard  in 
these  regions,  which  produce  local  symptoms — such  as  fre- 
quent colds,  imperfect  nasal  respiration,  etc. — should  receive 


568 


INFLAMMATION    OF    THE    LABYRINTH. 


proper  treatment,  as  variations  in  the  circulation  within  the 
labyrinth  are  thus  avoided. 

Where  extensive  involvement  of  the  labyrinth  of  both 
sides  is  present,  but  little  relief  can  be  hoped  for  by  the  cor- 
rection of  any  pathological  condition  within  the  tympanum  ; 
and  in  certain  instances,  especially  in  old  people,  surgical  in- 
terference is  positively  contraindicated,  as  the  progress  of 
the  disease  is  usually  rendered  more  rapid  by  these  measures. 
In  cases  of  extensive  unilateral  involvement,  such  measures 
may  be  justifiable  in  the  hope  of  preserving  the  opposite  ear, 
but  should  not  be  instituted  unless  there  is  positive  evidence 
that  the  diseased  organ  is  affecting  the  healthy  one. 


CHAPTER    XXXVI. 

ACUTE    INFLAMMATION    OF   THE   LABYRINTH    SECONDARY   TO 
ACUTE   PURULENT   OTITIS    MEDIA. 

iCtioIogy. — This  form  of  inflammation  of  the  labyrinth  is 
usually  confined  to  those  cases  in  which  the  middle-ear  affec- 
tion depends  upon  an  acute  infectious  disease,  such  as  scarlet 
fever,  diphtheria,  measles,  epidemic  influenza,  cerebro-spinal 
meningitis,  or  typhus  fever.  It  may  follow  a  severe  attack  of 
suppurative  otitis  media,  develof)ing  from  exposure  to  cold, 
from  a  traumatic  cause,  such  as  the  accidental  introduction  of 
fluid  into  the  tympanum,  or  rupture  of  the  membrana  tym- 
pani.  It  occurs  most  frequently  in  child  life,  at  which  period 
the  petrous  portion  of  the  temporal  separating  the  labyrinth 
from  the  middle  ear  is  thinner  and  of  less  density  than  later 
in  life.  In  order  that  the  entire  auditory  mechanism  should 
be  involved  in  an  inflammatory  process,  the  infection  must  be 
of  great  virulence,  and  this  depends  upon  the  severity  of  the 
acute  infectious  disease. 

Pathology. — This  condition  has  been  called,  not  inappro- 
priately,/^w^/z'/zs.  As  the  result  of  infection  within  the  mid- 
dle ear  the  softer  structures  rapidly  break  down,  while  the 
firmer  osseous  tissue  becomes  carious,  and  are  either  com- 
pletely destroyed  or  suffer  a  considerable  loss  of  substance. 
The  periosteum  covering  the  inner  tympanic  wall  takes  part 
in  these  changes,  and  not  infrequently  an  acute  inflammation 
of  the  underlying  osseous  tissue  results.  The  propagation 
of  the  condition  to  the  labyrinth  may  take  place  either  di- 
rectly through  the  diseased  bony  wall  or  at  the  labyrinthine 
windows.  Post-mortem  examination  frequently  shows  a  de- 
struction of  the  membrane  of  the  round  window,  or  a  loss  of 
substance  at  the  stapedio-vestibular  articulation,  the  infectious 
material  having  entered  through  these  channels.  The  tissue 
changes  which  take  place  do  not  differ  from  those  observed 
in  the  middle  ear.  Microscopic  investigation  reveals  the 
presence  of  the  bacilli  of  suppuration  both  in  the  blood  ves- 

(S<59) 


5;o    ACUTE  INFLAMMATION  OF  THE  LABYRINTH. 

sels  and  in  the  tissues.  Local  necrosis  occurs  early,  and  the 
firm  osseous  tissues  either  disintegrate  and  are  thrown  off  in 
the  profuse  secretion  incident  upon  the  inflammatory  process, 
or  the  necrosis  may  result  in  the  formation  of  a  sequestrum, 
which  is  either  discharged  spontaneously  or  is  removed  by 
suro-ical  interference.  The  condition  may  extend  from  the 
labyrinth  to  the  meninges,  either  along  the  sheath  of  the 
auditory  nerve  or  through  the  vestibular  or  cochlear  aque- 
ducts, causing  a  purulent  meningitis.  These  extensive  changes 
may  cause  partial  or  complete  destruction  of  the  end  organ 
of  the  auditory  nerve.  During  the  reparative  process  new 
osseous  tissue  may  be  deposited  and  obliterate  the  labyrin- 
thine cavity  to  a  greater  or  less  extent. 

Symptomatology. — Occurring  in  young  subjects  most  fre- 
quently, the  symptoms  depend  upon  the  intense  systemic  in- 
fection rather  than  upon  the  involvement  of  the  terminal 
portion  of  the  auditory  apparatus.  The  involvement  of  the 
labyrinth  in  consequence  of  an  acute  process  within  the  mid- 
dle ear  announces  itself  in  older  subjects  by  the  sudden  ap- 
pearance of  giddiness,  intense  tinnitus,  and  great  impairment 
of  hearing,  the  function  of  the  ear  being  completely  abolished 
in  many  cases.  When  the  inner  wall  becomes  involved  in  this 
manner,  facial  paralysis  is  not  uncommon,  owing  to  a  partial 
destruction  of  the  aqua:ductus  Fallopii,  exposing  the  facial 
nerve  to  infection.  Occasionally  dehiscences  are  found  in 
the  osseous  covering  of  the  facial  nerve  when  there  has  been 
no  pathological  process,  in  which  case  a  simple  inflammation 
of  the  middle  ear  produces  this  svmptom  without  causing 
a  loss  of  substance  in  the  wall  of  the  aquccductus  Fallopii, 
Hence,  facial  paralysis  alone  is  not  necessarily  an  evidence 
that  the  disease  has  involved  the  bony  walls.  The  interfer- 
ence with  equilibrium  mav  depend  upon  the  entrance  of  the 
infectious  material  into  the  vestibule,  or  the  horizontal  semi- 
circular canal  situated  high  up  on  the  inner  tympanic  wall 
may  be  the  seat  of  involvement ;  in  the  latter  case  disturb- 
ance of  equilibrium  alone  is  present,  while  the  function  of 
audition  is  scarcely  perverted  or  interfered  with.  The  most 
usual  avenue  of  extension  is  through  the  oval  and  round 
windows,  with  involvement  of  the  vestibule.  An  inflam- 
matory process  in  this  location  produces  the  characteristic 
symptoms  first  mentioned,  namely,  vertigo,  tinnitus,  and 
impairment  of  hearing.     As  the  case  progresses  the  vertigo 


SYMPTOMATOLOGY— DIAGNOSIS. 


571 


is  the  first  symptom  to  disappear  ;  next  the  tinnitus  becomes 
less  severe,  but  the  impairment  of  hearing  is  permanent. 
The  membranous  portions  of  the  cochlea  may  be  completely 
disintegrated,  and  the  bony  passages  are  sometimes  obliter- 
ated by  the  deposit  of  new  osseous  tissue.  In  many  instances 
a  large  part  of  the  petrous  portion  of  the  temporal  bone  is 
thrown  off  as  a  sequestrum.  Since  the  petrous  bone  lodges 
the  internal  carotid  artery  and  the  internal  jugular  vein, 
severe  haemorrhage  from  the  ear  is  not  an  infrequent  symp- 
tom of  this  extensive  destruction.  If  either  the  carotid  or 
jugular  is  eroded,  this  ha.morrhage  is  usually  fatal.  From 
the  proximity  of  the  cranial  contents,  direct  infection  of  the 
meninges  may  follow,  with  the  characteristic  symptoms  of 
meningitis.  It  is  probable  that  a  localized  inflammation  of 
the  labyrinthine  structures  in  the  immediate  neighboriiood  of 
the  fenestra  rotunda  sometimes  occurs,  without  spreading  to 
the  entire  labyrinth.  In  those  cases  which  do  not  terminate 
fatally,  the  hearing  for  the  upper  portion  of  the  musical  scale 
remains  greatly  impaired,  and  there  is  but  little  promise  of  a 
favorable  termination  under  an)-  plan  of  treatment.  A  por- 
tion of  specialized  end  organ  of  the  auditory  nerve  has  been 
completely  destroyed  by  the  disease,  and  manifestly  can  not 
be  regenerated  by  therapeutic  measures.  Any  portion  of  the 
cochlea  which  has  remained  intact  may  still  respond  to  the 
stimuli  of  sonorous  vibrations,  and  the  removal  of  certain 
conditions  which  interfere  with  its  proper  action  may  pre- 
serve the  remnant  of  the  auditory  functi(jn. 

Diagnosis. — A.  P/tysica/ R x a vii nation. — Speculum  examina- 
tion reveals  but  little  in  these  cases.  The  picture  is  one  of  a 
suppurative  otitis  media  of  gjeat  severity,  and  in  the  early 
stages  this  is  all  that  can  be  made  out.  At  a  later  period  the 
presence  of  carious  bone  gives  rise  to  the  formation  of  exuber- 
ant granulations  in  the  tympanic  cavity,  while  careful  exami- 
nation with  the  probe  may  reveal  denuded  areas  upon  the 
inner  tympanic  wall.  The  profuse  discharge  is  also  indica- 
tive of  extensive  tissue  necrosis,  and  where  carious  bone  is 
present  the  discharge  frequently  possesses  a  strong,  disagree- 
able odor.  The  presence  of  this  offensive  discharge  is  not  an 
invariable  evidence  of  dead  bone,  but  should  lead  to  a  strong 
suspicion  of  its  presence. 

B.  Functional  Examination. — In  young  subjects  an  exami- 
nation of    this  kind  is  manifestly  impossible.      Occurring  in 


-'J2         ACUTE    INFLAMMATION   OF   THE    LABYRINTH. 

patients  of  sufficient  age  to  answer  questions  intelligently,  it 
is  often  of  great  service  in  enabling  us  to  determine  the  pres- 
ence or  absence  of  the  condition  in  question.  Bone  conduc- 
tion is  either  completely  abolished  or  greatly  reduced.  The 
upper  tone  limit  is  lowered  to  such  a  degree  that  the  ear  may 
respond  to  no  vibrations  beyond  two  thousand  per  second. 
This  fact  is  explainable  on  anatomical  grounds.  Low  tones, 
on  the  contrary,  are  fairly  well  heard,  although  the  extensive 
destruction  which  has  taken  place  within  the  tympanum  ren- 
ders the  ear  less  susceptible  to  these  than  under  normal  con- 
ditions, or  in  cases  of  primary  labyrinthine  disease  in  which 
the  conducting  mechanism  is  not  affected.  If  we  add  to  this 
complete  loss  of  perception  of  high  musical  notes  the  loss  of 
bone  conduction  and  the  intense  vertigo,  we  have  a  combina- 
tion of  symptoms  which  can  mean  nothing  but  labyrinthine 
involvement. 

Prognosis. — The  prognosis  is  absolutely  unfavorable  as  to 
the  complete  restoration  of  the  function  of  the  organ,  the 
hearing  being  completely  destroyed  in  a  large  majority  of 
cases.  As  to  life,  the  outlook  is  equally  grave,  especially  in 
young  subjects.  In  adults,  extension  to  the  meninges  is  less 
common,  and  a  favorable  termination  may  be  hoped  for. 
Much  depends  upon  the  degree  of  infection,  and  this  varies 
with  the  disease  which  has  caused  the  inflammation  within 
the  tympanum.  The  poisoning  is  usually  so  profound  as  to 
give  little  hope  for  the  recovery  of  the  hearing,  even  if  the 
aural  complication  does  not  prove  fatal.  Complete  ablation 
of  audition  is  less  liable  to  take  place  in  adults  than  in  chil- 
dren, but  profound  interference  with  function  must  always  be 
looked  for.  At  an  early  age  this  termination  means  deaf- 
mutism,  and  it  is  our  duty  to  bear  this  in  mind  in  giving  an 
opinion. 

Treatment. — After  the  labyrinth  has  once  become  in- 
volved nothing  can  be  done  to  stay  the  progress  of  the  in- 
flammation. Our  duty  lies  chiefly  in  the  adoption  of  prophy- 
lactic measures,  in  all  cases  of  severe  suppurative  otitis,  for 
the  prevention  of  such  an  infection.  These  are  embraced 
under  the  head  of  thoroughly  cleansing  the  ear  by  frequent 
syringing,  keeping  the  tympanic  cavity  as  nearly  as  possible 
in  an  aseptic  condition.  Too  much  stress  can  not  be  laid  upon 
this  point,  since  the  practitioner  is  usually  so  much  occupied 
with  the  general  disease  that  he  can  give  but  little  attention 


TREATMENT.  573 

to  the  ears.  After  the  labyrinth  has  become  involved  the  parts 
should  still  be  kept  thoroughly  cleansed  by  syringing,  but  be- 
yond this  nothing  can  be  done.  Where  tinnitus  is  the  promi- 
nent symptom,  large  doses  of  hydrobromic  acid  or  of  sodium 
bromide  give  the  most  relief.  Extension  to  the  meninges  may 
be  combated  by  the  application  of  the  ice  cap  to  the  head,  free 
purgation,  and  absolute  rest.  During  the  acute  stages  noth- 
ing can  be  done  to  confine  the  involvement  of  the  labyrinth 
to  a  particular  area.  After  the  acute  symptoms  have  passed 
away  it  is  advisable  to  administer  the  muriate  of  pilocarpine, 
either  hypodermically  or  bv  the  mouth.  The  result  is  uncer- 
tain, but  in  several  cases  the  author  has  seen  exxcllcnt  results. 
Strychnine  should  also  be  given  in  full  doses  after  the  acute 
symptoms  have  passed. 


CHAPTER   XXXVII. 

INVOLVEMENT    OF    THE    PERCEPTIVE    MECHANISM    IN     IIIE 
ACUTE    INFECTIOUS   DISEASES. 

During  the  course  of  scarlatina,  diphtheria,  measles, 
mumps,  typhus  or  typhoid  fever,  variola,  influenza,  etc.,  the 
organ  of  hearing  is  not  infrequently  the  seat  of  marked 
pathological  changes.  In  scarlet  fever,  diphtheria,  measles, 
and  influenza,  and  to  a  less  degree  in  variola,  the  middle  ear 
is  the  part  first  attacked  in  most  cases,  and  any  labyrinthine 
involvement  is  due  to  an  extension  of  the  tympanic  inflam- 
mation. We  meet  with  instances,  however,  in  which  the 
specific  poison  exerts  a  direct  influence  upon  the  labyrinth, 
in  some  cases  the  middle  ear  remaining  health)-,  while  in 
others  there  has  evidently  been  a  double  infection,  the  laby- 
rinthine process  in  no  way  depending  upon  the  changes  which 
have  taken  place  in  the  tympanum. 

Pathology. — In  the  diseases  already  enumerated  the  poison 
is  conve3ed  to  the  labyrinth  through  the  blood  current,  and 
excites  an  inflammation  of  the  tissues  which  line  its  bony  chan- 
nels, in  some  cases  causing  a  disintegration  of  a  large  portion 
of  the  terminal  apparatus  of  the  auditory  nerve,  while  in 
others  the  local  process  does  not  reach  this  degree,  but  results 
in  an  effusion  of  fluid  into  the  labyrinthine  cavity,  with  the 
resulL  of  increasing  the  tension  upon  the  contained  parts,  as 
well  as  of  the  membranes  covering  the  round  and  oval  win- 
dows. If  the  effusion  is  sufficient  in  amount  to  overcome  the 
elasticity  of  these  limiting  membranes,  the  function  of  the 
labyrinth  is  for  a  time  perverted,  particularly  for  those  parts 
lying  immediately  in  the  neighborhood  of  the  round  and  oval 
windows.  It  is  probable  that  the  small  capillar}'  channels  of 
the  aqueducts  which  permit  any  excess  of  perilymph  to  pass 
into  the  intracranial  lymph  spaces  are  partially  occluded,  and 
hence  relief  to  pressure  in  this  direction  is  impossible.  Under 
these  conditions  the  disturbance  of  function  depends  entirely 

(574) 


SYMPTOMATOLOGY— DIAGNOSIS. 


s; 


upon  the  invasion  of  the  labyrinthine  cavity,  even  although 
the  middle  ear  may  have  been  the  seat  of  changes  as  well. 

Symptomatology. — These  cases  are  characterized  by  vary- 
ing degrees  of  impairment  of  hearing  and  rather  moderate 
subjective  noises.  In  the  milder  cases  in  adult  life  the  pa- 
tients hear  more  poorly  in  a  noise  than  in  a  quiet  place.  The 
impairment  of  hearing  is  particularly  marked  in  general  con- 
versation. In  other  instances,  and  when  the  primary  disease 
which  has  produced  the  condition  has  been  severe,  a  high 
degree  of  deafness  is  present,  the  voice  being  heard  only 
when  the  patient  is  spoken  to  loudly  in  the  immediate  vicinity 
of  the  ear.  The  exanthemata  are  particularly  prone  to  affect 
the  organ  of  hearing  in  this  way,  and  are  most  common  in 
childhood  ;  at  this  age  such  a  condition  must  lead  to  mutism 
unless  speedily  remedied,  and  the  recognition  of  the  nature 
of  the  process  is  of  greater  importance  in  childhood  on  this 
accoimt. 

Diagnosis. — The  diagnosis  in  these  cases  depends  upon 
the  fact  that  the  middle  ear  is  either  perfectly  healthy,  or 
presents  changes  which  are  evidently  incapable  of  producing 
the  degree  of  functional  impairment  present.  The  functional 
examination  is  characteiistic  of  labyrinthine  changes  rather 
than  of  those  met  with  in  a  lesion  of  the  conducting  aj)j)ara- 
tus.  The  lower  tone  limit  may  be  normal  or  but  slightly 
elevated,  even  although  extensive  changes  have  occurred 
within  the  tympanum.  The  upper  tone  limit  is  greatly  low- 
ered ;  bone  conduction  reduced  in  spite  of  the  presence  o(  a 
tympanic  lesion,  or  nearly  absent  where  the  tympanum  is  in 
a  healthy  condition.  Not  infrequently  tone  gaps  are  present 
in  the  upper  portion  of  the  musical  scale. 

Prognosis. — When  changes  are  of  recent  origin,  we  are 
warranted  in  believing  that  considerable  improvement  may 
follow  proper  therapeutic  measures,  anrl  in  cases  of  long 
standing  it  is  by  no  means  impossible  to  improve  the  condi- 
tion ver}'  materially.  In  childhood,  particularly,  internal 
medication  is  followed  by  the  happiest  results,  and  the  pa- 
tients should  always  have  the  benefit  of  the  doubt,  even  al- 
though the  case  may  seem  apparently  hopeless. 

Treatment. — For  the  reduction  of  labyrinthine  pressure 
and  the  absorption  of  the  exudation,  the  administration  of 
pilocarpine  first  in  small  doses — the  amount  being  rapidly 
increased  as  the  patient   becomes  accustomed   to  its   use — 


576      THE   EFFECT   OF   ACUTE    INFECTIOUS   DISEASES. 

causes  a  marked  improvement  in  the  hearing,  and  the  im- 
provement is  usually  permanent.  In  cases  of  long  standing 
the  torpidity  of  the  nerve  is  to  be  combated  by  the  use  of 
strychnine  as  well.  This  drug  must  be  administered  in  much 
laro-er  doses  than  those  ordinarily  recommended  in  order 
that  this  effect  may  be  produced.  An  additional  indication 
for  its  administration  is  to  combat  the  depression  which  the 
prolonged  use  of  the  pilocarpine  frequently  causes.  It  is 
scarcely  necessary  to  say  that  the  most  careful  attention 
must  be  paid  to  the  general  condition  of  the  patient,  and  in 
the  case  of  children  every  effort  is  to  be  employed  to  educate 
the  power  of  audition  as  it  improves. 

Having  considered  involvement  of  the  perceptive  appara- 
tus in  acute  infectious  diseases  from  a  general  point  of  view, 
a  few  remarks  may  not  be  out  of  place  in  regard  to  some  of 
the  particular  changes  following  certain  of  these  maladies. 

Mumps. 

Epidemic  parotiditis  is  particularly  prone  to  affect  the 
labyrinthine  structures  rather  than  the  middle  ear.  Recent 
investigations  seem  to  prove  clearly  that  this  local  inflamma- 
tion is  due  to  infection  from  the  blood  current  in  precisely 
the  same  manner  as  in  a  complicating  orchitis.  The  effect 
upon  the  perceptive  apparatus  is  usually  very  profound,  and 
its  occurrence  in  early  life  is  a  not  infrequent  cause  of  deaf- 
mutism. 

The  symptoms  detailed  above  are  all  characteristic  of 
labyrinthine  disease  dependent  upon  this  cause.  The  same  is 
true  of  the  diagnostic  measures  employed  and  the  therapeu- 
tic means  at  our  disposal. 

Regarding  the  prognosis  in  these  instances,  treatment  is 
followed  by  the  happiest  results  if  instituted  early.  When 
the  patient  does  not  come  under  treatment  until  a  considera- 
ble time  has  elapsed,  the  complete  restoration  of  function  can 
not  be  hoped  for,  although  moderate  improvement  may  be 
expected. 

Typhus  and  Typhoid  Fever. 

In  typhus  or  typhoid  fever  interference  with  sound  per- 
ception is  probably  due  to  the  changes  which  the  specific 
poison  of  the  disease  causes  in  the  cerebrum  itself  rather  than 
to  any  effect  upon  the  terminal  filaments  of  the  nerve.     That 


INFLUENZA— DIPHTHERIA— EPIDEMIC   MENINGITIS. 


577 


this  is  the  case  seems  to  be  borne  out  when  we  consider  the 
degree  of  impairment  of  hearing  which  these  patients  fre- 
quently present,  and  its  disappearance  during  the  period  of 
convalescence. 

Epidemic  Influenza;  DiniTHERiA. 

In  epidemic  influenza,  and  in  some  cases  of  diphtheria,  it  is 
probable  that  the  perceptive  apparatus  occasionally  suffers 
through  changes  in  the  auditory  nerve  trunk  similar  to  those 
occasionally  found  in  the  optic  nerve  following  these  diseases. 
These  are  of  the  nature  of  a  peripheral  neuritis,  and  involve 
the  nerve  trunk  to  a  varying  degree.  As  a  result,  sclerotic 
changes  occur  with  atrophy  of  the  nerve  fibres. 

The  interference  with  function  will  depend  upon  the  ex- 
tent of  the  lesion,  and  the  possibility  of  restoring  the  parts  to 
a  normal  condition  will  depend  upon  the  same  fact.  The 
condition  is  characterized  by  an  interference  with  the  percep- 
tion of  the  middle  notes  of  the  musical  scale,  the  tone  limits 
remaining  normal.  Bone  conduction  is  not  destroyed  com- 
pletclv,  although  it  is  much  diminished.  The  galvanic  irrita- 
bility of  the  nerve  is  usually  increased. 

The  treatment  should  be  directed  toward  the  improve- 
ment of  the  general  condition  of  the  patient.  Mental  and 
physical  rest  should  be  secured.  The  food  should  be  of  the 
most  nourishing  quality,  while  the  general  neurasthenic  con- 
dition should  be  combated  by  the  administration  of  strych- 
nine. After  the  acute  symptoms  have  subsided,  this  drug 
should  be  given  in  large  doses,  to  secure  its  well-known  spe- 
cific effect  upon  the  nerve  tissues. 

Epidemic  Cerebro-spinal  Meningitis. 

Pathology. — In  scarlet  fever,  diphtheria,  measles,  mumps, 
typhus  and  typhoid  fever,  variola,  epidemic  influenza,  etc.,  the 
primary  invasion  of  the  labyrinth  occurs  by  direct  infection 
through  the  blood  current.  When  the  meninges  are  invaded 
by  the  specific  germ  of  the  disease  under  consideration,  the 
inflammatory  process  extends  along  the  lymph  channels  of  the 
vestibular  and  cochlear  aqueducts,  and  involves  the  structures 
located  within  the  bony  labyrinth.  During  the  early  stages 
both  the  perilymph  and  endolymph  are  increased  in  quantity, 
while  at  the  same  time  their  composition  undergoes  a  change 

39 


578      THE   EFFECT   OF   ACUTE    INFECTIOUS   DISEASES. 

through  the  action  of  the  specific  germ.  Later,  the  bony 
walls  are  the  seat  of  inflammatory  changes.  Both  the  ar- 
teries and  veins  become  dilated.  There  is  a  migration  of 
white  blood  cells  into  the  surrounding  tissues,  and  true  tissue 
hypertrophy  takes  place.  From  the  extensive  proliferation 
of  the  blood  vessels  themselves  in  the  newly  deposited  tissue, 
the  walls  of  these  channels  are  of  unusual  tenuity  and  rupture 
easily.  Hence  extravasation  of  blood  constitutes  one  of  the 
conditions  found.  The  newly  deposited  tissue  increases  in 
density,  and  may  be  transformed  into  bone,  in  which  case  the 
semicircular  canals  or  cochlea  are  partially  or  completely 
obliterated.  In  other  portions  the  chief  force  of  the  disease 
expends  itself  in  tissue  necrosis  ;  the  labyrinthine  channels 
being  filled  with  pus.  Occasionally  the  tympanum  is  invaded 
secondarily  by  a  rupture  of  the  membrane  at  the  round  or 
oval  windows,  allowing  the  inflammatory  products  to  escape 
into  the  middle  ear.  From  the  tympanic  involvement  the 
drum  membrane  is  soon  destroyed,  and  a  purulent  otorrhoca 
manifests  itself.  Naturally  this  condition  is  somewhat  rare, 
as  death  usually  takes  place  before  sufficient  time  has  elapsed 
for  its  completion. 

Symptomatology.  —  In  addition  to  the  symptoms  charac- 
teristic of  meningeal  inflammation,  we  have  vertigo,  sudden 
loss  of  hearing,  and  intense  tinnitus.  In  very  young  chil- 
dren the  vertigo  may  be  the  only  evident  symptom,  on  ac- 
count of  the  age  of  the  patient.  Occurring  in  older  indi- 
viduals, the  access  of  subjective  noises  is  usuallv  sudden, 
while  their  intensity  is  so  great  as  to  be  agonizing.  The 
hearing  is  either  completely  destroyed  at  once,  or  this  con- 
dition occurs  at  the  end  of  a  few  hours  after  the  appearance 
of  the  symptoms.  Preceding  these  marked  evidences  of  labv- 
rinthine  invasion,  the  power  of  audition  mav  be  abnormally 
acute,  probably  from  the  hvperaemic  condition  of  the  laby- 
rinthine structures.  This  hvperacusis  may  be  so  marked  that 
faint  sounds  even  are  painful,  the  patient  starting  at  the  slight- 
est noise,  and  complaining  of  an  increase  in  the  headache 
characteristic  of  meningitis.  After  a  short  time  the  subjective 
noises  diminish,  owing  to  the  destruction  of  the  terminal  fila- 
ments of  the  eighth  nerve,  and  the  hearing  remains  pro- 
foundly impaired  for  the  same  reason.  The  power  of  equi- 
librium gradually  returns,  although  this  is  more  slow,  per- 
haps, than  the  disappearance  of  the  subjective  noises.     The 


DIAGNOSIS— PROGNOSIS. 


579 


involvement  of  the  middle  ear  is  evidenced  by  the  ordinary 
symptoms  of  an  acute  purulent  inflammation  arising  from 
anv  other  cause. 

Diagnosis. — A.  Physical  cxamiuation  is  of  importance  in 
that  it  yields  absolutely  negative  results,  the  membrana  tym- 
pani  and  meatus  presenting  a  normal  appearance.  From  the 
absence  of  any  deviation  froni  the  standard  of  health,  togeth- 
er with  the  presence  of  subjective  symptoms  referable  to  the 
ears,  suspicion  is  naturallv  directed  toward  the  nervous  ap- 
paratus. 

Functional  Examination. — B.  Impairment  of  hearing,  both 
for  sharp  sounds  and  speech,  is  either  profound  or  the  patient 
is  absolutely  deaf.  If  any  power  of  audition  remains,  it  is 
usually  for  the  low  notes  of  the  scale,  the  higher  notes  not 
being  heard  at  all.  Rare  exccjitions  are  found  where  the 
apex  of  the  cochlea  is  first  involved.  This,  however,  occurs 
but  seldom  ;  in  fact,  the  lower  notes  of  the  scale  may  be  heard 
with  abnormal  clearness  during  the  stage  of  hvpera^nia  on 
account  of  the  hypcrasthctic  condition  of  the  nerve.  Bone 
conduction  is  greatly  diminished,  and  after  a  few  hours  is 
absolutely  lost.  It  may  be  completelv  absent,  although  the 
ear  mav  still  perceive  sounds  by  aerial  conduction. 

Prognosis. —  If  the  patient  recovers  from  the  meningeal 
inflammation  the  outlook  for  the  preservation  of  hearing  is 
exceedingly  grave.  In  severe  cases  absolute  deafness  results, 
while  in  the  milder  instances  a  certain  amount  of  audition 
may  be  preserved.  The  disappearance  of  the  subjective 
noises  is  a  rather  unfavorable  symptom,  since  it  denotes  com- 
plete anresthesia  of  the  auditory  nerve  or  perceptive  centres, 
and  often  absolute  destruction  of  the  terminal  nerve  filaments. 
The  involvement  of  the  labyrinth  in  no  way  affects  the  prog- 
nosis  as  regards  life.  This  disease  is  of  particular  moment 
when  met  with  in  vcrv  carlv  life,  since  the  loss  of  the  audi- 
tory perception  renders  the  patient  mute  as  well  as  deaf. 
This  is  true  even  if  the  child  has  learned  to  talk  fairly  well, 
such  words  as  have  been  learned  being  forgotten.  In  older 
children  mutism  may  not  follow,  since  the  association  between 
written  and  spoken  words  is  sufficient  to  preserve  the  power 
of  speech.  The  effect  of  treatment  is  usually  unsatisfactory 
in  the  severe  cases,  although  in  the  less  severe  cases,  where  a 
certain  amount  of  hearing  has  been  preserved,  the  function  of 
the  organ  may  be  still  further  improved. 


58o 


THE   EFFECT   OF   ACUTE    INFECTIOUS    DISEASES. 


Treatment. — But  little  can  be  done  to  prevent  the  exten- 
sion of  the  meningeal  inflammation  to  the  labyrinth.  With 
the  development  of  the  hyperacusis  it  is  wise  to  apply  cold 
locally  to  the  mastoid  process,  while  at  the  same  time  free 
bloodletting  is  advisable,  provided  the  general  condition  of 
the  patient  will  admit  of  this.  Free  catharsis  should  also  be 
obtained  if  the  general  condition  does  not  contraindicate  it. 
If  our  efforts  are  unsuccessful,  nothing  can  be  done  until  the 
acute  symptoms  have  subsided,  after  which  the  reduction  of 
labyrinthine  pressure  by  the  use  of  pilocarpine,  either  ad- 
ministered hypodermically  or  b}-  the  mouth,  is  always  advis- 
able, and  is  frequently  followed  by  favorable  results.  This 
is  true,  although  the  patient  may  not  present  for  treatment 
until  a  considerable  period  after  the  attack  of  meningitis,  and 
where  a  careful  examination  seems  to  indicate  that  even  a 
small  portion  of  the  cochlea  has  escaped  destruction,  the  util- 
ity of  the  organ  can  usually  be  improved.  In  addition  to  the 
pilocarpine,  strychnine  in  large  doses  is  an  agent  of  consider- 
able value  in  preventing  a  rapid  degeneration  of  the  nerve 
fibres  in  the  trunk,  from  the  changes  which  have  taken  place 
in  the  labyrinth.  When  the  acute  svmptoms  have  completely 
subsided,  exercise  of  the  organ,  either  through  the  agency  of 
the  human  voice — a  conversation  tube  being  used,  if  necessary 
— or  by  the  employment  of  some  instrument  based  upon  the 
principle  of  the  phonograph,  may  still  further  improve  the 
hearing.  It  is  to  be  specially  remembered  that  both  dynamic 
and  therapeutic  measures  must  be  continued  for  a  long  period 
in  order  to  be  of  the  least  value,  and  any  slight  gain  is  to  be 
looked  upon  as  encouraging.  It  is  wise,  in  case  pilocarpine 
is  to  be  administered  for  a  long  period,  to  occasionally  stop 
it  altogether  for  an  interval  of  one  to  three  weeks,  after  which 
it  is  to  be  resumed,  beginning  with  small  doses.  The  general 
condition  of  the  patient  must  always  be  kept  as  near  normal 
as  possible,  and  all  conditions  are  to  be  avoided  which  disturb 
the  labyrinthine  circulation  either  directly  or  indirectly. 


CTTAPTKR    XXXVIIT. 

INVOLVEMENT   OF  THE    PERCEPTIVE    MECHANISM    IN   ACUTE 

MENINC.ITIS. 

Pathology. — McninjE^itis  of  the  noncpidcmic  type  may  pro- 
duce secondary  changes  in  the  labyrinth  in  the  same  manner 
as  the  epidemic  form  of  the  disease.  A  traumatic  meningitis 
is  usually  localized,  and  consequently  the  labyrinthine  in- 
volvement is  unilateral  as  a  rule.  In  addition  to  direct  exten- 
sion through  the  labyrinthine  aqueducts,  the  function  of  audi- 
tion may  be  interfered  \yith  either  by  direct  pressure  of  the 
products  of  inflammation  upon  the  auditory  nerye  trunk,  or 
by  the  involyement  of  the  nerve  sheath  itself  in  the  process, 
or  by  a  localized  meningitis  oyer  the  cortical  auditory  area. 
When  the  labyrinth  is  the  scat  of  the  lesion,  the  jiroccss  difTers 
from  that  met  with  in  the  ej)idemic  variety  of  the  disease,  in 
that  it  is  less  extensiye  and  seldom  leads  to  the  comi)lete  de- 
strviction  of  the  j)arts  within  the  bony  caj)sule.  I'ressure 
upon  the  nerye  trunk  causes  degenerati(jn  of  the  nerye  fibres 
according  to  well-known  physiological  laws,  but  seldom 
causes  a  destruction  of  all  the  fibres  of  the  trunk.  A  cortical 
lesion  presents  essentially  the  same  characteristics  in  that  the 
entire  sensory  area  is  seldom  destroyed. 

An  idiopathic  meningitis  interferes  with  the  auditory 
function  in  the  same  manner,  the  exact  pathological  process 
depending  upon  the  location  of  the  intracranial  lesion. 

Symptomatology. — The  symptoms  will  vary  according  to 
the  particular  location  of  the  meningeal  inflammation.  Where 
direct  extension  to  the  labyrinth  occurs,  subjectiye  noises  of 
varying  intensity,  moderate  or  severe  vertigo,  and  a  varying 
degree  of  impairment  of  hearing  are  present.  The  severity 
of  each  of  these  symptoms  will  depend  upon  the  extent  to 
which  the  labyrinth  is  invaded.  Where  the  trunk  of  the 
nerye  is  attacked  the  same  conditions  are  present,  although 
here  the  auditory  impairment  is  the  prominent  symptom,  and 
is  usuall}'  most  pronounced  for  the  middle  notes  of  the  scale, 

(581) 


-82   THE  PERCEPTIVE  MECHANISM  IN  ACUTE  MENINGITIS. 

perception  for  high  and  low  notes  being  fairly  well  preserved. 
In  either  case  the  impairment  of  function  is  unilateral,  the 
opposite  organ  remaining  perfectly  healthy. 

Meningitis  over  the  convexity  of  the  brain  involving  the 
cortical  perceptive  area  interferes  with  the  function  of  both 
ears,  the  defect  being  most  marked  upon  the  side  opposite  to 
the  cortical  area  involved. 

If  the  affection  is  labyrinthine  there  is  but  little  tendency 
to  an  increase  in  the  symptoms,  but  rather  to  a  spontaneous 
retroo-ression.  Where  the  nerve  trunk  or  the  cortical  cen- 
tres are  the  parts  primarily  involved,  the  symptoms  increase 
or  diminish  according  as  the  meningitis  becomes  more  dif- 
fuse or  yields  to  appropriate  therapeutic  agents.  In  trau- 
matic cases  the  area  affected  may  be  so  located  as  to  cause 
an  interference  with  equilibrium  alone,  the  hearing  remain- 
ing intact,  while  tinnitus  is  absent.  Another  symptom  quite 
characteristic  is  the  development  of  hyperacusis  or  dysacusis, 
this  latter  svmptom  corresponding  to  the  familiar  ocular 
disturbance,  photophobia,  so  characteristic  of  meningeal  in- 
flammation. 

Lesions  involving  the  cortical  areas,  or  the  paths  of  com- 
munication within  the  brain  itself,  produce  the  quite  char- 
acteristic symptom  of  word  deafness;  the  sound  is  heard  but 
is  not  interpreted,  or,  if  interpreted,  is  recognized  imperfectly 
or  slowly.  A  somewhat  similar  condition  presents  when  the 
trunk  of  the  nerve  is  involved,  on  account  of  the  interference 
with  the  middle  portion  of  the  musical  scale.  As  this  por- 
tion of  the  register  is  the  one  ordinarilv  emplovcd  in  conver- 
sational speech,  the  power  of  interpreting  language  is  some- 
what perverted,  especially  when  the  conversation  is  general. 
Complete  deafness  for  any  particular  word  or  combination 
of  sounds  does  not  exist,  however,  but  simply  impairment. 
Again,  as  we  shall  see,  the  complete  functional  examination 
of  the  case  enables  us  to  distinguish  with  considerable  ex- 
actness between  the  two  conditions.  While  a  labyrinthine 
lesion  in  the  early  stages  is  characterized  by  distressing  tin- 
nitus, any  inflammation  of  the  meninges  which  causes  either 
pressure  upon  the  nerve  or  upon  the  cortical  perceptive  area 
does  not,  as  a  rule,  present  this  characteristic.  Where  pres- 
sure is  exerted  upon  the  trunk  of  the  nerve,  atrophy  takes 
place  quite  early ;  hence  any  noise  which  may  have  been 
present  in  the  incipient  stage  may  disappear ;  and  the  same 


DIAGNOSIS— FUNCTIONAL    EXAMINATION.  583 

is  true  where  the  lesion  is  cortical.  The  future  progress  of 
the  case  will  depend  upon  the  intracranial  changes  present. 
In  traumatic  meningitis  the  disappearance  of  the  acute  local 
lesion  will  either  be  followed  by  a  rapid  decrease  in  the 
symptoms  if  the  products  of  the  inflammation  are  absorbed, 
or  the  condition  may  remain  permanent,  there  being  no  tend- 
ency to  progression.  This  is  true  of  those  cases  where 
either  an  epidural  or  cerebral  abscess  does  not  follow.  If 
either  of  these  conditions  is  present  the  symptoms  increase 
as  the  localized  collection  of  pus  becomes  augmented  in 
volume. 

Diagnosis. — Our  diagnosis  will  depend  upon  the  history 
either  of  a  traumatism,  or,  in  idiopathic  cases,  of  symptoms 
characteristic  of  meningeal  inflammation.  Ii!xamination  by 
means  of  the  speculum  will  reveal  the  parts  in  a  normal  con- 
dition, or,  in  the  case  of  injury  to  the  head,  there  may  be  evi- 
dences of  rupture  of  the  membrana  tympani ;  and  it  must  be 
borne  in  mind  that  when  these  signs  are  present  there  is 
more  difficulty  in  determining  the  actual  condition  of  the 
perceptive  apparatus  on  account  of  the  tympanic  complica- 
tion. When  no  middle-ear  lesion  exists,  a  determination  of 
the  exact  portion  of  the  perceptive  tract  involved  dej)ends 
entirely  upon  tiie  functional  examination  and  upon  the  ante- 
cedent history. 

Functional  Exaunnation. —  Where  the  lesion  is  labyrinthine, 
the  lower  tone  limit  is  usually  normal,  the  upjier  tune  limit 
much  lowered,  bone  conduction  very  slight  or  absent,  while 
the  impairment  of  hearing  for  the  conversational  voice  is 
relatively  less  than  that  for  high-pitched  sounds.  If  the  lesion 
is  so  extensive  as  to  cause  impairment  for  the  conversational 
voice,  this  is  seldom  of  a  moderate  degree,  but  the  deafness  is 
almost  absolute.  Paracusis  Willisii  is  absent.  Artificial  aids 
to  hearing  do  not  improve  the  auditory  power,  and  the  pa- 
tient becomes  greatly  fatigued  after  attempting  to  exert  the 
power  of  audition  for  any  considerable  period,  the  hearing 
becoming  rapidly  worse,  and  evidences  of  severe  mental  exer- 
tion manifest  themselves.  The  reaction  to  the  galvanic  cur- 
rent reveals  usually  a  condition  of  marked  hyperassthesia 
when  the  lesion  is  recent.  In  cases  of  long  standing  this  con- 
dition may  be  replaced  by  one  of  torpidity.  When  the  trunk 
of  the  nerve  is  pressed  upon,  the  upper  and  lower  tone  limits 
vary  but  little  from  normal.    The  notes  of  the  middle  register 


584 


THE  PERCEPTIVE  MECHANISM  IX  ACUTE  MENINGITIS. 


are  poorly  heard,  and  bone  conduction  is  either  absent  or 
diminished  to  a  marked  extent.  In  testing  bone  conduction 
in  these  cases  several  tuning  forks  of  different  pitch  should  be 
used,  since  the  nerve  may  react  perfectly  to  forks  of  one 
pitch  while  it  does  not  respond  to  others.  The  electrical  re- 
action shows  a  persistent  hyperccsthetic  condition,  the  degree 
of  hypersesthesia  varying  but  little  on  succeeding  days,  and 
being  replaced  by  one  of  torpidity  in  the  late  stages  only. 

When  the  cortical  centre  is  implicated  the  presence  of  tone 
gaps  is  a  characteristic  symptom.  The  most  certain  evidence 
of  involvement  of  the  cortical  area,  however,  is  the  appearance 
of  Avord  deafness.  The  patient  hears  isolated  sounds,  and 
even  spoken  words,  but  finds  it  impossible  to  repeat  sjioken 
words  or  to  correctly  interpret  their  meaning.  Naturally  the 
lesion  is  bilateral,  although  the  impairment  is  more  marked 
upon  the  side  opposite  the  involved  area.  Bone  conduction 
in  these  cases  is  diminished,  but  seldom  absent  on  account  of 
decussation  of  the  fibres.  The  tone  gaps  may  be  present  in 
any  portion  of  the  scale.  The  galvanic  current  may  reveal 
hyperassthesia  or  some  other  deviation  from  the  normal  stand- 
ard, such  as  a  reversal  of  the  normal  reaction  formula,  or  a 
paradoxical  reaction.  This  latter  term  is  used  to  designate 
the  condition  in  which  stimulation  of  the  organ  of  one  side 
produces  phenomena  on  the  opposite  side.  The  concomitant 
symptoms  ordinarily  are  sufficicntlv  marked  to  confirm  the 
diagnosis  in  cases  where  cortical  involvement  is  suspected. 

Prognosis. — If  we  exclude  meningitis  due  to  abscess  and 
intracranial  tumors,  the  process  is  not  progressive  in  cases 
where  the  lesion  remains  intracranial.  In  tlic  same  manner, 
although  to  a  less  degree,  an  extension  to  the  labvrinth  sel- 
dom presents  this  tendency,  the  process  being  limited  to  the 
immediate  area  first  involved. 

In  rendering  an  opinion,  therefore,  we  may  confidently 
state  that  the  hearing  will  improve  rather  than  diminish  as 
age  advances. 

Treatment. — In  the  acute  stage  our  measures  of  treatment 
are  confined  to  those  directed  toward  meningeal  inflamma- 
tion. After  the  acute  stage  is  past,  if  the  lesion  is  laby- 
rinthine, the  administration  of  pilocarpine  hastens  the  absorp- 
tion of  the  effusion  within  the  labyrinth,  and  causes  a  rapid 
improvement  in  function  provided  complete  destruction  has 
not  taken  place.     From  the  well-known  action  of  the  iodide 


TREATMENT.  585 

of  potassium  on  recent  inllanimatory  exudates  it  is  well  to 
combine  this  drug  with  the  pilocarpine  in  moderate  doses. 
Where  the  lesion  is  intracranial,  the  administration  of  iodide 
of  potassium  for  a  considerable  period  in  moderate  doses  is 
probably  the  best  means  at  our  command.  Coincident  with 
this  wc  mav  give  strychnine  in  the  form  of  the  sulphate  or 
nitrate,  beginning  with  small  doses  and  increasing  the  amount 
to  the  point  of  tolerance.  It  must  be  remembered  that  the 
administration  of  strychnine  should  not  be  begun  until  all 
acute  symptoms  have  disappeared.  In  cases  of  intracranial 
involvement  the  careful  and  systematic  use  of  some  apparatus 
desitrned  to  moderatclv  stimulate  the  auditorv  nerve  by  so- 
norous  vibrations  is  of  undoubted  value.  The  particular  de- 
vice is  of  but  little  importance,  and  may  vary  from  a  simple 
conversation  tube  to  a  more  complicated  instrument.  It  is 
important  that  the  stimulation  of  the  nerve  in  this  manner 
shall  not  be  carried  too  far,  as,  where  it  is  too  prolonged,  the 
function  of  the  nerve  is  blunted  rather  than  preserved. 


CHAPTER   XXXIX. 

THE   EFFECT   OF   DISEASES   OF   THE   GENERAL   NERVOUS 
SYSTEM   UPON   THE   PERCEPTIVE    MECHANISM. 

We  have  already  considered  the  result  of  the  acute  in- 
flammatory conditions  met  with  in  the  meninges,  and  there 
remains  for  discussion  those  affections  which  are  character- 
ized by  degenerative  changes  in  the  various  parts  of  the 
brain.  These  are  cerebral  congestion,  apoplexy,  cerebral  em- 
bolism, endarteritis,  cerebral  tumors,  disseminated  sclerosis, 
and  tabes  dorsalis.  From  the  location  of  the  cortical  audi- 
tory centres,  and  the  fact  that  each  auditory  centre  receives 
fibres  from  the  labvrinth  of  either  side,  any  cortical  lesion  must 
be  bilateral  and  extensive  to  produce  absolute  deafness  upon 
either  side.  The  crossing  of  the  auditory  fibres  takes  place  in 
the  medulla  in  the  region  of  the  olivary  bodies,  and  an  intra- 
cranial lesion  upon  one  side  could  only  produce  total  deaf- 
ness in  one  ear  when  situated  between  the  foramen  of  exit  of 
the  auditorv  nerve  and  the  corresponding  olivary  body.  A 
tumor  at  the  base  of  the  skull  might  possibly  produce  this 
effect,  but  we  find  that  neoplasms  seldom  occur  in  this  region. 

Investigation  of  cases  of  cerebral  haemorrhage  and  of  em- 
bolism show  that  in  comparatively  few  instances  is  the  organ 
of  hearing  affected  to  a  perceptible  degree.  Even  if  the  cen- 
tre upon  one  side  is  largelv  destroyed,  its  place  is  supplied  by 
the  corresponding  area  in  the  opposite  cerebral  hemisj)here, 
and  the  impairment  in  function  is  but  slight. 

The  symptom  most  characteristic  of  a  cortical  lesion  is 
known  as  "  word  deafness."  Here  words  are  heard  but  not 
understood,  the  patient  simplv  obtaining  the  general  impres- 
sion of  sound  without  being  able  to  interpret  it.  A  subjec- 
tive symptom  characteristic  of  the  cortical  involvement  is 
the  presence  of  certain  complex  auditorv  impressions  or  hal- 
lucinations. The  patient  seems  to  hear  voices,  the  conversa- 
tion either  being  directed  to  him.  or  he  niav  simjilv  be  the 
listener.     Among  musicians  these  hallucinations  may  assume 


CORTICAL    LESIONS— TABES.  587 

the  character  of  well-known  musical  selections  performed  by 
an  orchestra.  The  sufTerer  is  able  to  follow  each  instrument 
as  it  performs  its  special  part,  and  is  frequently  tormented  by 
the  impression  that  one  or  more  is  slightly  out  of  tune.  The 
exact  pathological  condition  in  the  cortex  exerts  but  little  in- 
fluence upon  the  symptoms,  and  may  be  either  congestive. 
ha^Miiorrhagic,  degenerative,  sclerotic,  or  neoplastic.  Transi- 
tory subjective  disturbances  of  this  character  are  probably 
due  to  either  cerebral  congestion  or  anaemia.  The  possibil- 
ity of  locating  a  pathological  process  within  the  brain  itself 
depends  upon  the  presence  of  associated  nervous  symptoms 
due  to  the  coincident  involvement  of  contiguous  areas,  while 
at  the  same  time  an  examinatit)n  of  the  ear  reveals  the  con- 
ducting mechanism  to  be  in  nearly  a  normal  condition. 

In  tabes  dorsalis   the  changes  which  have  been  recognized 
consist  in  an  extension  of  the  sclerotic  process  to  the  auditory 
nerve  itself,  or  to  its  centres.     It  is  characteristic  of  all  affec- 
tions  of  the  acoustic  nerve  trunk  that  the  electric  excitability 
is  increased  until  degenerative  changes  are  so  far  advanced 
that  the   function  of  the  ear  is  entirely  lost.     A  permanent 
hypera-sthesia  of  the  nerve,  therefore,  is  strongly  indicative 
of  intracranial  disease  if  peripheral  irritali(jn  can  be  excluded 
in   the  given  case.     The   j)orlion  of  the  musical  scale  most 
affected  is  usually  the  middle  notes  of  the  register,  the  upper 
and    lower    tone   limits    being   normal.     Where    the   cortical 
areas  are  involved  the  same  hypera.'sthesia  may  be  met  with. 
As   distinguished    from    labyrinthine    lesion,   any    change    in 
labyrinthine  pressure  brought  about  by  artificial  means,  such 
as  inflation  of  the  tympanum,  will  exert  but  little  influence 
ui)on  the  perception  of  sound  thnnigh  the  bones  of  the  skull. 
In   labyrinthine   disease,   the    disturbance    from    labyrinthine 
pressure  brought  about  in  this  way  usually  diminishes  bone 
conduction.     It  is  also  to  be  remembered  that  until  a  high 
degree  of  atrophv  has  been  reached  bone  conduction  is  pre- 
served when  the  symptoms  are  due  to  an  intracranial  growth.^' 
In   discussing   the   symptoms   in    the   previous   pages    we 
have    confined    ourselves    to   the   hypothesis    that    the    intra- 
cranial  process  was  confined    to   the   cerebrum.     When   the 
cerebellum  is  involved,  disturbance  of  equilibrium  occurs,  to- 
gether with  nausea,  while  there  may  be  no  impairment  in  the 

•  Politzer,  Diseases  of  the  Ear,  American  edition,  p.  587. 


588 


EFFECT   OF   DISEASES   OF   THE    NERVOUS   SYSTEM. 


hearing.  Changes  in  the  trunk  of  the  nerve  may  give  rise  to 
disturbances  of  equilibrium,  as  well  as  to  subjective  noises 
and  impairment  of  hearing. 

Practically  the  diagnosis  in  these  cases  depends  more 
upon  the  associated  symptoms  characteristic  of  the  general 
nervous  affection  than  upon  the  aural  manifestations.  The 
absence  of  any  evident  condition  within  either  the  conduct- 
ing mechanism  or  labyrinth  which  is  capable  of  producing 
the  symptoms,  while  at  the  same  time  the  evidence  of  the 
general  nervous  affection  is  marked,  is  the  chief  aid  to  diag- 
nosis. 

Reo-ardinsf  medication  but  little  can  be  said.  The  chief 
indications  for  treatment  will  be  furnished  by  the  general 
nervous  disease.  If  the  aural  symptoms  are  pronounced, 
they  should  be  treated  according  to  the  directions  already 
given.  For  the  subjective  noises  the  bromides  will  usually  be 
found  most  efficacious.  U  there  arc  evidences  of  faulty  nutri- 
tion of  the  nerve  tissue,  strychnine  in  large  doses  will  often  be 
of  benefit  in  preventing  the  total  loss  of  function.  From  the 
possibility  of  a  specific  taint  large  doses  of  the  iodide  of  po- 
tassium should  be  given  in  anv  case  if  there  is  evidence  of 
intracranial  involvement. 


SECTION    \' 


COM  PLICA  TL\U    A  L  K.  I L    PISE.  I SPS. 


COMPLICATIXG    Al'RAL    DISHASES. 


CIIAPTI-R    XT.. 

AURAI,   AFFECTIONS   COMl'LICATINe;    THE   ACUTE   INFECTIOUS 

DISEASES. 

We  have  already  considered  the  changes  which  may  take 
place  in  the  perceptive  portion  of  the  auditory  mechanism 
from  the  acute  infectious  diseases.  In  addition  to  these,  the 
conducting  aj)paratus  is  a  frequent  site  of  pathological  condi- 
tions from  the  same  cause.  In  a  majority  of  cases  the  acute 
infectious  disease  produces  an  inflammation  of  the  middle  ear 
when  this  organ  of  special  sense  is  in  any  way  involved.  It 
may  be  stated,  as  a  general  rule,  that  the  severity  of  the  inflam- 
mation within  the  tympanum  corresponds  in  degree  to  that  of 
the  exciting  cause.  Thus,  in  the  milder  exanthemata — such  as 
measles,  varicella,  mild  influenza,  and  in  mumps — an  affection 
of  the  middle  ear  is  usually  contincd  U)  the  lower  portion  of  the 
cavitv.  constituting  either  a  tubal  catarrh  or  an  acute  catar- 
rhal otitis  media.  If  rupture  of  the  drum  membrane  takes 
place,  the  discharge  is  serous  or  sero-mucous  in  character, 
and  onlv  becomes  purulent  by  infection  from  without.  In  the 
more  severe  infectious  diseases— such  as  severe  cases  of  rubeola, 
scarlatina,  variola,  tyi»hus  fever,  and  diphtiicria — the  infection 
is  more  virulent,  and  here  the  connective-tissue  structures  are 
the  chief  seat  of  involvement.  In  other  words,  the  otitis 
media,  which  complicates  the  diseases  just  named,  has  its 
origin  in  the  upper  portion  of  the  tympanic  cavity,  and  con- 
stitutes in  reality  a  cellulitis.  This  cellulitis  follows  the  course 
typical  of  such  a  process  in  any  portion  of  the  body,  and  very 
quickly  results  in  extensive  tissue  necrosis,  the  soft  structures 
breaking  down  with  the  formation  of  pus,  while  after  a  com- 
paratively short  interval  the  contiguous  bony  structures  be- 
come affected  and  rapidly  disorganize.     It  is  probable  that  in 

(59') 


592    COMPLICATIONS   OF  ACUTE    INFECTIOUS   DISEASES. 

a  given  case  the  selection  of  the  lower  or  upper  portion  of  the 
tympanic  cavity  as  the  seat  of  process  depends  entirely  upon 
the  deo-ree  of  infection  rather  than  upon  the  selection  of  any 
particular  region  by  various  organisms,  the  lower  portion 
being  involved  in  the  milder  cases,  while  the  upper  part  is 
attacked  in  the  more  severe  forms  of  infectious  disease.  Bac- 
teriological investigation  goes  to  show  that  the  germ  charac- 
teristic of  the  particular  disease  is  not  so  much  the  cause  of 
the  otitis  media  as  are  the  bacteria  of  suppuration,  and  that 
the  number  of  these  last-named  germs  present  depends  en- 
tirely upon  the  degree  of  systemic  infection. 

It  may  seem  that  this  line  is  rather  sharply  drawn,  as 
many  cases  present  in  which  at  first  it  is  almost  impossible  to 
reconcile  clinical  experience  with  this  theory.  A  careful  study 
of  manv  cases  has  convinced  me  that  where  these  anatomical 
boundaries  are  transgressed  this  departure  is  always  marked 
by  a  corresponding  change  in  the  general  symptoms  of  the 
patient.  Thus  in  epidemic  influenza  of  a  mild  type,  or  in  a 
mild  case  of  measles,  we  should  expect  the  lower  portion  of 
the  tympanum  to  be  involved,  the  characteristic  signs  being  a 
comparatively  slight  amount  of  pain  in  the  ear,  of  short  dura- 
tion, and  quickly  followed  by  the  effusion  of  serum  or  sero- 
mucus.  Where  the  quantity  of  fluid  is  not  sufficient  to  cause 
rupture  of  the  membrana  tympani  the  fluid  may  remain  in  the 
middle  ear  for  a  considerable  length  of  time.  During  this 
period  the  temperature  will  remain  moderately  elevated,  or 
may  reach  normal  if  the  process  is  entirely  quiescent.  Sud- 
denly the  temperature  rises  rapidly,  the  patient  exhibits  con- 
siderable prostration,  and  the  pain  in  the  car  returns.  An 
examination  will  now  reveal  that,  in  addition  to  the  effusion 
already  present  in  the  lower  portion  of  the  tympanic  cavity, 
there  are  unmistakable  evidences  of  involvement  of  the  vault. 
The  fluid  in  the  middle  ear  is  a  culture  medium  which  favors 
the  development  of  pathological  bacteria,  and  if  these  are  still 
present,  invasion  of  the  upper  portion  of  the  cavity  may  take 
place  at  any  time.  In  the  same  manner  those  cases  where 
the  process  at  first  seems  confined  to  the  uj^per  portion  of  the 
cavity,  but  does  not  go  on  and  rupture  through  Shrajmell's 
membrane,  may  remain  quiescent  for  several  days,  the  tem- 
perature becoming  normal  and  the  pain  in  the  car  disap- 
pear, although  the  local  manifestations,  such  as  redness  above 
the  short  process  and  above  the  anterior  and  posterior  liga- 


SYMPTOMATOLOGY. 


593 


nients,  still  continues.  A  sudden  rise  of  temperature,  with 
pain  in  the  affected  organ,  is  accompanied  by  a  bulging  of  the 
entire  posterior  quadrant,  and  a  rai»id  extension  of  the  redness 
to  the  region  of  the  membrana  vihrans.  Here  the  products  of 
inflammation  have  passed  into  the  atrium,  following  the  long 
process  of  the  incus  ;  and  the  involvement  of  the  atrium  is  to 
be  looked  upon  as  a  secondary  infection,  giving  rise  to  distinct 
symptoms.  It  is  scarcely  necessary  to  call  to  mind  the  clinical 
importance  of  the  facts  already  stated  when  we  remember 
that  any  inHammation  in  the  upper  portion  of  the  tynijianic 
cavity  always  constitutes  a  disease  of  considerable  gravity, 
and  one  which  demands  prompt  measures  for  its  relief,  while 
an  inflammation  of  the  atrium  is  comparatively  simple  if  we 
can  confine  it  to  this  region.  According,  then,  as  our  gen- 
eral disease  is  mild  or  severe,  we  may  predict  with  consider- 
able certainty  a  corresponding  degree  of  aural  involvement. 
The  exact  method  of  dealing  with  these  conditions  has  already 
been  sufficieiillv  dilated  upon. 


40 


CHAPTER   XLI. 

AURAL   AFFECTIONS   DEPENDENT   UPON    CHRONIC    VISCERAL 

CONDITIONS. 

In  general,  we  may  state  that  any  changes  within  tlic  vis- 
cera produce  disturbances  referable  to  the  ear  chictly  from 
their  efTect  upon  the  general  venous  circulation.  Where  the 
venous  flow  through  the  larger  viscera  is  obstructed,  a  dam- 
ming back  of  the  return  current  from  the  internal  ear  results, 
leading  in  time  to  a  dilatation  of  the  venous  channels  within 
the  auditory  apparatus.  This  is  particularly  true  of  the  laby- 
rinth, and,  as  already  mentioned,  constitutes  a  common  cause 
of  labyrinthine  congestion.  Within  the  middle  ear  or  within 
the  meatus  corresponding  changes  may  occur,  as  evidenced 
by  an  increased  vascularity  in  the  parts  and  a  greater  tor- 
tuosity of  the  minute  veins. 

NkI'HKITIS. 

In  nephritis,  the  pathological  conditions  found  in  the  organ 
of  hearing  depend  both  upon  the  obstruction  to  the  general 
venous  circulation  and  also  upon  that  condition  of  the  arteries 
so  frequently  met  with,  known  as  arterio-capillary  fibrosis. 
As  the  result  of  these  changes  within  the  vessel  walls,  the  tis- 
sues are  poorly  supplied  with  blood,  the  result  being  that  the 
entire  economy  is  in  a  condition  below  the  normal  standard 
of  health.  The  quality  of  the  blood  circulating  within  the 
vessels  is  also  impoverished,  its  fluid  elements  being  relatively 
increased. 

Within  the  tvmpanum  these  changes  in  the  vessels  and  in 
the  quality  of  the  blood  frequently  result  in  a  transudation 
of  serum  through  the  vessel  walls,  the  lesion  being  similar  to 
that  of  pleural  efTusion  in  nephritis.  This  condition  should 
not  be  looked  upon  as  an  inflammation,  although  it  is  fre- 
quently called  otitis   media  serosa.     The   process  is  entirely 

(5<>4) 


NEI'HRITIS— METASTASIS. 


595 


mechanical,  and  the  fliiitl  is  the  result  of  transudation,  and 
not  of  an  intlaniination.  The  fluid  within  the  cavitv  niav  be 
absorbed  sjtontaneouslv,  or  may  remain  for  an  indefinite  pe- 
riod. When  the  middle  ear  is  in  tiiis  condition  it  is  more 
liable  to  become  the  seat  of  a  mild  catarrhal  inflammation 
than  under  normal  conditions.  Coincident  with  the  effusion 
there  is  usually  a  partial  or  complete  stenosis  of  the  Plusta- 
chian  tube,  due  to  passive  congestion  of  the  lining  membrane, 
w  ith  a  diminution  of  atmospheric  pressure  within  the  middle 
ear.  This  change  favors  the  passage  of  fluid  from  the  blood 
vessels  into  the  tympanic  cavity,  and  the  process  tends  to  effect 
j)ermanent  changes.  From  the  weakness  of  the  vessel  walls 
rupture  is  not  uncommon,  and  hacmorrhagic  otitis  media,  or, 
more  properly,  ha^mato- tympanum,  is  occasionally  found. 
These  haemorrhages  may  also  occur  in  the  external  auditory 
canal,  or  between  the  layers  of  the  drum  membrane  itself. 
Similar  changes  may  take  place  within  the  labyrinth,  in  one 
case  causing  an  increase  in  labyrinthine  pressure  either  by  an 
augmentation  in  the  quantity  of  j)erilymph  or  by  actual  ha.'m- 
orrhajre  into  the  labyrinthine  channels.  In  the  latter  instances 
the  extravasation  of  blood  may  destroy  the  end  organ  of  the 
auditory  nerve  over  a  given  area,  rendering  it  useless  and  inca- 
pable of  performing  its  function.  Fhis  will  lead  to  absolute 
deafness  to  the  particular  sound  which  this  jiortion  of  the 
cochlea  perceived.  1  lainorrhagic  changes  in  the  sheath  of 
the  auditory  nerve  may  also  complicate  a  chronic  ncj)hritis. 
The  blood  sup|>ly  of  the  labyrinth  is  derived  from  several 
channels,  and  hence  the  occlusi(jn  of  one  of  these  efferent 
vessels  might  take  place  without  seriously  im{)airing  the  func- 
tion of  the  j)art,  the  blood  supply  being  maintained  through 
the  collateral  circulation. 

Ml.T.\STASIS. 

An  extensive  suppurative  process  in  any  portion  of  the 
body,  such  as  an  acute  osteomyelitis  or  bony  caries,  or  necro- 
sis located  in  any  region,  may  be  the  point  of  origin  of  infec- 
tious emboli.  These  are  carried  through  the  various  circula- 
tory channels,  either  into  the  middle  ear  or  labyrinth,  and 
their  lodgment  produces  symptoms  dependent  upon  the  shut- 
ting off  of  the  blood  supply  of  the  parts  beyond,  or  by  a  local- 
ized secondary  infectious  process  which  they  excite.  It  is 
not  improbable  that  chronic  suppuration  within  the  accessory 


5q6   complications  of  chronic  visceral  lesions. 

sinuses  of  the  nasal  cavity  is  responsible  for  many  obscure 
aural  symptoms  met  with  in  these  cases.  The  entrance  of  an 
embolus  into  the  blood  current  from  one  of  the  accessory  si- 
nuses, and  its  subsequent  passage  into  the  labyrinthine  vessels, 
is  the  most  plausible  explanation  of  the  cases  of  mild  tinnitus 
and  sudden  impairment  of  hearing  of  moderate  degree  which 
are  frequently  met  with.  In  ulcerative  endocarditis,  an  in- 
fection either  of  the  internal,  middle,  or  external  ear  may 
take  place  in  the  same  manner,  from  a  dctaclimcnt  of  the  vege- 
tations on  the  cardiac  valves. 

In  acute  pulmonary  affections,  particularly  pneumonia,  an 
acute  middle-ear  inflammation  may  result  from  the  passage 
of  the  infectious  germ  through  the  blood  current  and  its 
lodgment  in  the  tympanic  mucous  membrane.  It  is  probable 
that  certain  cases  are  due  to  the  entrance  of  germs  through 
the  Eustachian  tube.  The  degree  to  which  the  middle  ear  is 
involved  will  depend  upon  the  severity  of  the  pulmonary 
process;  if  this  is  severe,  the  aural  inflammation  will  be  sup- 
purative, while  in  the  milder  cases  it  is  a  simple  catarrhal 
inflammation,  or  may  cease  spontaneously  at  the  stage  of  con- 
gestion. 

TunERCULOSis. 

In  tuberculosis,  the  involvement  of  the  middle  ear  is  char- 
acterized by  the  insidious  manner  in  which  the  infection  de- 
velops, frequently  the  first  symptom  which  the  patient  recog- 
nizes being  discharge  from  the  ear,  there  having  been  no 
pain  or  noticeable  impairment  of  hearing  ]>rcvious  to  this 
time.  On  examination,  the  entire  drum  membrane  may  be 
wanting,  and  in  some  cases  the  ossicula  themselves  mav  have 
become  involved.  Where  the  destruction  of  the  membrane 
has  taken  place  over  a  limited  area  the  perforation  presents 
a  somewhat  characteristic  appearance.  It  is  usually  circular, 
the  edges  are  thick  and  everted,  and  present,  instead  of  the 
bright-red  color  commonly  observed  in  a  simple  perforation 
of  the  membrana  tympani,  a  blue-white,  glossy,  oedematous 
appearance  comparable  to  that  seen  over  the  arvta:noid  car- 
tilages in  laryngeal  tuberculosis.  Another  condition  which 
is  somewhat  characteristic  is  the  appearance  of  two  or  more 
distinct  perforations  in  the  membrane.  Where  the  ossicles 
are  involved,  the  surrounding  bony  structures  are  quickly 
attacked,  and  the  entire  mastoid   may  be  broken  down  even 


TUBERCULOSIS— LEUC.EMIA.  597 

at  a  very  carlv  period.  It  is  imi)ortant  to  recognize  llie  dis- 
ease in  its  incipiency,  as  prompt  removal  of  the  affected  parts 
may  check  the  progress  and  relieve  to  a  degree  the  sys- 
temic condition  dependent  upon  it.  Usually,  when  the  organ 
ol  hearing  is  attacked,  the  pulmonarv  or  visceral  involvement 
is  an  affair  of  so  much  greater  gravity  than  the  aural  affec- 
tion as  to  make  this  latter  insigniticant.  If.  from  the  severity 
of  the  symptoms,  or  in  the  hope  of  stopping  the  progress 
of  the  affection  it  is  deemed  advisable  to  attack  the  local 
icsicjn,  we  should  remember  that  anv  operative  measures  will 
be  greatly  aided  bv  the  administration  of  those  drugs  which 
seem  to  exert  a  specihc  inlliKiice  ujxiu  the  tubercular  pio- 
cess. 

The  nutrition  of  the  patient  should  be  j)articulai"ly  at- 
tended to.  Cod-liver  oil,  the  hvi)Oj)hosphites,  and  the  vari- 
ous preparations  of  malt  are  all  of  value  in  the  various  cases, 
and  much  is  to  be  said  in  favor  of  the  administration  of  creo- 
sote in  (loses  of  one  half  to  three  grains  three  or  four  times 
dailv.  While  I  do  not  wish  it  to  be  understood  that  the  tym- 
panic lesion  demands  treatment  in  a  large  majority  of  cases, 
or  that  radical  treatment  directed  to  this  part  is  advisable,  it 
is  well  to  bear  in  mind  the  possibility  of  systemic  infection 
from  this  focus,  and  also  the  fact  that  the  local  |)rocess  is  sure 
to  extend  rapidly,  and  is  hence  more  easily  checked  in  its 
early  stage  than  after  it  has  existed  for  a  considerable  jxriod. 

Leuc.i:mia. 

In  leuca.'mia  a  form  of  deafness  is  found  depending  ui)on 
the  ])assageof  minute  cells  orlymj)h  corpuscles  into  the  laby- 
rinthine channels  (Fig.  152).  narrowing  their  calibre  and  in 
time  even  leading  to  a  complete  obliteration  (jf  their  lumen. 
In  the  earlv  stages  this  deposit  is  cellular  in  structure;  but  if 
the  patient  survives  the  disease  for  a  long  time,  organization 
of  this  tissue  may  take  place,  and  the  obliteration  of  the  laby- 
rinthine passages  is  effected  by  an  osseous  deposit,  the  symp- 
toms depending  upon  the  extent  of  the  local  process  and  upon 
its  severity.  It  is  recognized  by  the  presence  of  the  gen- 
eral leuca^mic  condition,  and  with  the  sudden  appearance  of 
deafness  which  gradually  grows  worse,  together  with  vertigo, 
nausea,  and  subjective  noises.  The  functional  examination 
reveals  a  lesion  of  sound-perceiving  apparatus  ratherlhan  one 


598     COMPLICATIONS   OF   CHRONIC   VISCERAL   LESIONS. 

referable  to  those  parts  concerned  in  sound  transmission. 
Practically  nothing  can  be  done  to  stay  the  progress  of  the 
affection,  our  efforts  at  treatment  being  as  futile  as  those  em- 
ployed to  combat  the  constitutional  affection. 


r- 
aa;— 

J.S.- 


- V 


1'  . 

/lOO 


ss 


C.£. 


^ 


Fig.  152. — Section  through  the  middle  turn  of  the  cochlea  in  a  case  of  leucaemia, 
showing  infiltration,  (tlradenigo.*)  O,  Bone  ;  S.  I'.,  Scala  vcstibuli ;  S.  T., 
Scala  tympani  ;  L.  S.,  Ligamentum  spiralis;  A.  I'.,  Stria  va.scularis ;  N.F., 
Nerve  expansion  in  the  lamina  spiralis;  e,fyg,  Membrana  tectoria  ;  A,  Inner 
hair-cells;  w,  «,  Corti's  rods  ;  a,  /,  d,  Limbus  lamina  sjiiralis;  /,  Epithelium  of 
sulcus  spiralis  internus  ;  /,  Epithelium  of  sulcus  spiralis  externus  ;  C.  E.,  Outer 
cells  of  Corti  and  Deiter  ;  c,  c,  I,  Claudius's  cells. 


Arch,  fiir  Ohrenheilk  ,  vul.  xxiii.  p.  242. 


DIABETES— GOUT— RHEUMATISM. 


599 


DiAHKTKS. 

Ill  severe  cases  of  diabetes  the  most  characteristic  affec- 
tion retcrable  to  the  car  is  tlie  occurrence  of  acute  circum- 
scribed external  otitis.  When  we  remember  how  prone  the 
diabetic  jiatient  is  to  furunculosis,  we  can  explain  the  occur- 
rence of  the  aural  lesion  upon  the  same  ground.  Eczema  of 
the  auricle  and  canal  is  also  ot  common  occurrence.  Within 
the  tvmj)anum  there  is  scarcely  anv  condition  characteristic 
of  diabetes,  although  it  is  probable  that  all  structures,  includ- 
ing those  of  the  middle  ear,  are  more  liable  to  attacks  oi  in- 
flammation than  under  normal  conditions.  Symptoms  refer- 
able to  the  sound-perceiving  apparatus  probably  depend  upon 
either  labyrinthine  haemorrhage  or  extravasation  into  the  me- 
dullary or  cortical  centres.  The  repair  of  anv  lesion  sponta- 
neously is  slow  in  these  cases.  When  the  condition  is  an 
acute  inflammatorv  one,  supjuiration  is  the  rule.  This  is 
worthy  of  note  where  the  mastoid  process  becomes  involved 
consecutive  to  an  inflammation  within  the  canal  or  middle 
ear.  Often,  in  spite  of  the  greatest  precaution,  prolonged 
su[)puration  occurs;  and  while  we  should  not  be  deterred 
from  oj)erating  upon  diabetic  patients  for  this  reason,  efforts 
to  secure  perfect  asepsis  must  be  vigorously  enforced. 

Ciol'l"    ANh    RllIMMAI  ISM. 

Gout  and  rheumatism  probably  exert  a  greater  influence 
upon  the  organ  of  hearing  than  is  usually  siP)posed.  it  is 
not  necessary  that  the  patient  shall  have  ever  been  the  victim 
of  an  acute  gouty  or  rheumatic  attack,  the  hereditary  diathet- 
ic condition  being  sufficient  to  induce  pathological  changes 
within  the  ear.  While  the  cases  dependent  upon  gout  or 
rheumatism  as  the  sole  cause  are  probably  rare,  any  acute  or 
chronic  inflammatory  process  arising  from  some  other  cause 
is  modified  to  a  marked  degree  through  these  diatheses. 
Thus  in  numerous  cases  of  nonsuppurative  otitis  media  our 
measures  for  relief  may  be  without  result  until  internal  medi- 
cation is  directed  toward  the  correction  of  the  gouty  or  rheu- 
matic taint.  In  the  canal  itself  a  persistent  eczema  rather 
mild  in  character  is  frequently  met  with  in  patients  suffering 
from  a  gouty  diathesis.  Although  in  itself  this  inflammation 
would  scarcely  attract  the  attention  of  the  patient,  it  leads  to 
a  condition  of  the  cutaneous  linins:  of  the  canal  which  favors 


6oo     COMPLICATIONS    OF    CHRONIC    VISCERAL    LKSIONS. 

the  development  of  vegetable  parasites.  When  these  have 
once  crained  lodgment  in  the  meatus,  the  local  inHammation 
which  they  excite  by  their  presence  is  sufficient  to  produce 
marked  symptoms  from  which  the  patient  seeks  relief. 

Treatment  of  the  local  condition  will  probably  be  without 
avail  unless  the  gouty  diathesis  is  at  the  same  time  borne 
in  mind  and  combated.  In  the  tympanum  itself  we  find  in 
rare  instances  an  inflammation  of  the  interossicular  articula- 
tions which  is  probably  rheumatic  in  nature.  The  local  ap- 
pearances are  confined  to  the  immediate  region  of  the  articu- 
lation. The  pain  is  severe,  the  constitutional  disturbance 
marked  and  out  of  proportion  to  the  local  lesion,  and  efforts 
to  afford  relief  are  unsuccessful  until  antirheumatic  drugs  are 
administered.  The  symptoms  abate  under  this  plan  of  medi- 
cation, and  the  disease  follows  the  course  of  an  acute  articu- 
lar rheumatism  of  any  of  the  larger  joints.  It  was  formerly 
supposed  that  the  gouty  diathesis  exerted  a  peculiar  influence 
upon  the  development  of  exostoses  within  the  bony  meatus, 
but  this  theory  has  not  been  borne  out  by  subsequent  investi- 
gation. Of  much  more  importance  is  the  influence  which 
this  diathetic  condition  exerts  upon  the  walls  of  the  blood 
vessels.  Arterial  degeneration  takes  place,  the  vessels  be- 
coming rigid  through  the  deposit  of  lime  salts  in  their  walls, 
thus  narrowing  the  calibre  and  so  weakening  the  walls  that 
they  are  easily  ruptured  by  any  sudden  increase  in  blood 
pressure.  These  effects  are  most  marked  within  the  labyrinth, 
and  give  rise  to  subjective  noises,  giddiness,  and  slight  im- 
pairment in  hearing.  In  advanced  cases  the  occurrence  of 
capillary  haemorrhages  also  serves  to  explain  many  of  the 
symptoms  met  with. 

MkDICIXAI.    Sl'nSTANCKS. 

The  ingestion  of  certain  medicinal  substances  exerts  a 
specific  influence  upon  the  organ  of  hearing.  Of  these,  the 
most  prominent  is  quinine.  Salicin,  salicylic  acid  and  its 
salts  exert  a  similar  influence  in  a  less  degree.  In  general 
these  changes  constitute  in  mild  cases  a  congestion  both  of 
the  middle  ear  and  of  the  labyrinthine  structures.  When  any 
drugs  of  this  character  are  administered  in  excessive  doses 
this  hyperaemia  may  lead  to  rupture  of  the  vessels,  causing 
minute  haemorrhages.  When  administered  for  a  long  period, 
even    in    moderate    doses,  the  chronic    congestion  produces 


MEDICINAL   SUBSTANCES.  6oi 

structural  chan^-cs  particularlv  within  the  labyrinth,  which 
do  not  disappear  even  after  the  administration  of  the  drug  is 
stopped.  When  the  car  is  in  a  normal  condition  it  is  probable 
that  serious  injury  following  the  exhibition  of  these  drugs  is 
comparatively  rare  ;  but  where  the  ear  is  the  seat  of  a  chronic 
inflammatory  process,  or  is  particularly  susceptible  to  cir- 
culatory changes,  their  use  is  to  be  guarded  against.  It  is 
manifestly  impossible  to  prevent  the  use  of  these  remedies  in 
all  cases  of  chronic  aural  disease,  but  tiiey  should  never  be 
given  except  in  an  extremitv,  and  then  should  be  exhibited 
in  small  doses,  and  discontinuctl  as  soon  as  i)ossiblc.  The 
habit  of  {prescribing  large  doses  of  quinine  for  a  cold  in  the 
licad  can  not  be  too  strongly  prohibited. 

The  moderate  use  of  tobacco  innncnces  the  organ  of  hear- 
ing but  slightlv,  whether  the  parts  arc  in  a  state  of  health  or 
disease.  It  was  former! v  supj>oscd  that  its  use  aggravated 
anv  pre-existing  catarrhal  inllanimation  of  the  upper  air  tract, 
and  in  this  wav  aggravated  chronic  alTections  of  the  tym- 
l)anum.  The  danger  in  the  use  of  tobacco  does  not  lie  in 
this  direction,  but  rather  in  the  elTect  which  the  drug  exerts 
upon  the  general  nervous  system,  if  the  habitual  use  of  to- 
bacco produces  constitutional  disturbances  referable  to  the 
general  nervous  system,  there  is  no  question  about  the  advis- 
ability of  stopping  it  at  once.  That  it  should  exert  any  spe- 
cific action  upon  the  organ  of  hearing,  while  the  general 
nervous  organism  escapes,  is  exceedingly  improbable.  We 
may  practicallv  disregard  any  action  upon  the  conducting 
mechanism  ;  and  if  the  receptive  portion  of  the  auditory  sys- 
tem suffers  from  its  habitual  use,  we  shall  have  confirmatory 
evidence  from  its  effect  upon  other  portions  of  the  nervous 
system.  The  particular  region  of  the  perceptive  tract  af- 
fected is  i)robably  either  the  nerve  trunks  or  centres  them- 
selves. 


CHAPTER    XLII. 

DISTURBANCES   OF   AUDITION   DEPENDENT    UPON    FUNCTIONAL 
NERVOUS    DISORDERS. 

The  most  common  functional  disturbances  of  the  nervous 
system  which  produce  any  marked  effect  upon  the  organ  of 
hearino"  are  those  known  under  the  terms  "neurasthenia" 
and  "  hysteria." 

Since  the  exact  nature  of  these  conditions  is  at  present 
problematical,  the  manner  in  which  they  influence  the  vari- 
ous  portions  of  the  sound-perceiving-  mechanism  is  a  mat- 
ter of  conjecture.  In  certain  instances  neurasthenic  or  hys- 
terical patients  will  present  marked  disturbances  referable  to 
the  organ  of  hearing.  These  disturbances  probably  depend 
upon  some  slight  pre-existing  jiathological  condition  which 
ordinaril}'  would  pass  unnoticed.  The  lesion  may  lie  cither 
in  the  meatus  or  in  the  tympanic  cavity,  and  be  entirely  un- 
recognizable upon  careful  examination  ;  but  as  it  constitutes 
the  point  of  least  resistance  in  the  nervous  svstem,  the  mani- 
festation of  a  neurasthenic  or  hvsterical  condition  is  exhibited 
here  rather  than  in  another  locality.  The  reason  for  believing 
this,  is  that  where  a  moderate  affection  of  the  sound-conduct- 
ing mechanism  exists,  the  disturbance  of  function  is  out  of  all 
proportion  to  the  pathological  condition  present ;  and  in  addi- 
tion to  these  symptoms,  which  are  characteristic  of  involve- 
ment of  the  transmitting  apparatus,  certain  other  manifesta- 
tions present  which  can  oiilv  be  explained  by  the  abnormal 
general  condition. 

Neurasthenia. 

In  neurasthenia  the  entire  nervous  svstem  seems  to  be 
overtaxed  by  even  a  moderate  effort ;  and  where  the  function 
of  any  one  organ  is  impaired,  as  in  the  cases  under  considera- 
tion— the  organ  of  hearing — this  impairment  is  magnified  to  a 
great  degree.  In  general  these  cases  are  characterized  by 
the  symptom  which  may  be  termed  "auditory  strain."     In 

(6oa) 


NEURASTHENIA.  603 

conversation  with  one  individual  the  patient  hears  fairly  well, 
and  the  hearing  is  usually  better  early  in  the  morning.  After 
being  subjected  to  the  fatigue  consequent  upon  the  day's  ac- 
tivitv,  the  hearing  power  becomes  much  diminished,  and  any 
effort' on  the  part  of  the  i>atient  to  disguise  the  symptom 
simply  magnifies  it.  The  local  impairment,  in  turn,  reacts 
upon  the  general  condition  of  the  patient  to  a  considerable 
degree,  frequently  causing  him  to  become  hypochondriac, 
and  in  some  cases  leading  to  acute  melancholia.  The  hearing 
is  more  impaired  in  a  noisy  than  in  a  quiet  room;  tinnitus  is 
present,  and  varies  greatly  in  degree,  being  more  marked 
when  the  patient  is  tired.  In  addition  to  these  subjective  symp- 
toms, certain  others  manifest  themselves,  such  as  a  feeling  of 
formication  in  the  canal ;  a  feeling  of  occlusion  in  the  meatus,  as 
though  a  foreign  body  were  present;  or  a  sensation  ol  irritation 
referred  either  to  the  Eustachian  orifice  or  to  the  base  of  the 
tongue.  Often  during  the  process  of  examination  the  hear- 
inglluctuatcs  greatly.  H  patients  can  be  convinced  that  no 
test  is  being  made,  they  frequently  respond  to  questions 
asked  in  a  moderate  tone  of  voice ;  as  soon,  however,  as  they 
become  aware  that  tiie  power  of  audition  is  being  estimated 
their    anxietv    to    hear   causes    a    marked    diminution    in    the 

power. 

Diagnosis.  -.\s  said  before,  certain  deviations  from  the 
normal  standard  may  be  found  upon  speculum  examination, 
or  these  departures  fnjm  the  normal  may  be  so  slight  as  to 
be  entirely  overlooked.  Functional  examination  is  a  matter 
of  considerable  difficultv,  especially  if  any  recognized  lesiim 
of  the  conducting  apparatus  is  present,  the  answers  of  the  pa- 
tient being  verv  misleading  unless  the  general  condition  is 
borne  in  mind.  '  As  a  rule,  low  tones  are  well  heard,  the  low- 
est limit  of  the  scale  being  frequently  preserved,  even  where 
inspection  shows  a  marked  alteration  in  the  conducting 
mechanism.  The  upper  tone  limit  may  be  moderately  low- 
ered, but  is  occasionally  elevated,  and  the  high  notes  may  be 
painful.  Bone  conduction  is  diminished,  while  sharp  sounds, 
such  as  the  tick  of  a  watch  or  the  click  of  the  acou meter,  give 
varying  results,  being  heard  at  one  time  exceedingly  well,  at 
anothe?  time  poorly  or  not  at  all.  The  voice  is  usually  heard 
better  relatively  than  either  the  watch  or  acoumeter. 

The    most  valuable  aid  in    diagnosis  is  a  comparison  of 
the  results  obtained  by  functional  examination  with  the  gen- 


6o4     INFLUENCE    OF    FUNCTIONAL    NERVOUS    DISEASES. 

cral  history  of  the  case.  When  we  consider  the  undue  im- 
portance which  these  patients  attach  to  the  slii;ht  subjective 
symptoms  of  which  they  complain — referable  to  the  meatus, 
the  yault  of  the  pharynx,  or  region  oi  the  Eustachian  tube 
— we  can  readily  understand  why  the  results  of  functional 
examination  should  be  so  at  variance  with  what  might  be 
.  expected. 

The  hyperacusis  which  is  quite  commonly  observed  in 
these  cases  explains  the  preservation  of  the  lower  tone  limit 
even  when  this  should  be  considerably  elevated.  We  are 
apt  to  be  misled  also  by  this  symptom,  for  quantitative 
tests  may  yield  entirely  negative  results,  the  patient  hear- 
ing the  watch,  acoumeter,  or  whispered  speech  at  the  normal 
distance.  Continuing  the  examination  for  some  time,  we 
shall  usually  find  that  the  organ  soon  becomes  tired  and  the 
hearing  power  rapidly  diminishes.  This  fatigue  manifests 
itself  not  only  for  any  one  sound,  but  when  this  condition  is 
reached  all  sounds  are  poorly  perceived.  This,  we  must  re- 
member, is  a  marked  deviation  from  the  normal  standard. 
In  health,  although  the  sonorous  vibrations  of  any  given 
pitch  will,  after  a  time,  so  fatigue  the  perceptive  centres  as 
to  reduce  the  power  of  audilit>n  for  that  {particular  sound, 
yet  this  impairment  of  function  does  not  invariably  occur 
with  the  perception  of  sounds  of  different  pitch,  but  rather 
renders  the  hearing  of  them  more  acute,  in  order  to  test 
the  ease  with  wiiich  the  ear  is  fatigued  it  is  onlv  necessary 
to  make  use  of  a  tuning  fork  of  512  V.  S.,  or  the  octave 
above  this,  and  maintain  the  fork  in  vibration  close  to  the  ear 
for  a  period  of  five  to  ten  minutes,  setting  it  in  \ibration 
anew  as  soon  as  its  note  becomes  weak.  If  the  fork  is  struck 
with  approximately  equal  force  each  tiine,  it  will  be  found 
that  the  period  during  which  its  vibrations  are  perceived  will 
become  shorter  and  shorter.  In  some  cases  we  find  that  the 
ear  very  quickly  ceases  to  perceive  the  note  of  the  fork.  If 
now  the  instrument  is  removed  from  the  ear  for  a  few  sec- 
onds, and  then  again  brought  immediately  in  front  of  the 
meatus,  the  note  will  again  be  heard,  although  the  instru- 
ment has  not  been  set  in  vibration  afresh,  and  hence  the 
sound  is  less  intense  than  when  it  was  removed  from  in  front 
of  the  ear.  This  is  called  a  secondary  perception  of  the  note. 
In  marked  instances  we  find  even  tertiary  or  quaternary 
perceptions.     This  phenomenon  corroborates    the  statement 


TREATMENT    OF    NEURASTHENIA— HYSTERIA.  Tos 

of  the  patient  that  the  power  of  audition  is  poorest  in  listen- 
ing to  general  conversation. 

Prognosis. — Aside  from  any  organic  changes  which  may 
be  present  either  in  the  middle  ear  or  labyrinth,  the  prog- 
nosis will  depend  upon  our  ability  to  control  the  general 
nervous  condition.  This  is  difficult,  and  the  outcome  of  such 
a  case  must  always  be  uncertain.  If  the  jiatient  can  be  per- 
suaded to  think  less  about  his  hearing,  there  is  fair  \u)\)c  that 
the  power  of  audition  will  improve. 

Treatment. — No  drugs  exert  a  specific  action  upon  the 
central  portion  of  the  auditorv  appaiatus  in  this  condition, 
and  the  treatment  of  defective  hearing  will  resolve  itself  into 
the  treatment  of  neurasthenia.  vStrychnine  in  large  doses,  as  a 
nerve  tonic,  is  of  use  in  a  considerable  proportion  of  cases. 
Where  the  strvchnine  increases  the  excitability  of  the  pa- 
tient, this  mav  be  controlled  by  the  administration  of  bro- 
mide of  sodium  in  proper  doses  at  the  same  time.  W'e  thus 
overcome  the  reHex  excitabilitv  produced  bv  the  first  drug, 
while  we  in  no  wav  diminish  its  action  as  a  nerve  tonic  and 
as  a  stimulant  to  the  nervous  centres.  A  complete  change 
of  scene  is  advisable,  and  where  the  disease  has  resulted 
from  prolonged  mental  exertion  it  is  well  to  interdict  work 
of  this  kind.  This  is  bv  no  means  an  absolute  rule,  as  a  con- 
siderable proportion  of  patients  do  not  imi)rove  unless  their 
minds  are  occuj>ied  in  some  manner.  A  complete  change  of 
occupation  is  desirable  in  these  cases,  since  they  may  become 
so  interested  in  tin  ir  work  as  to  forget  themselves,  and  thus 
second  our  efforts  in  restoring  their  normal  condition. 

1  h  SlKklA. 

This  affection  is  closelv  allied  to  the  one  just  described, 
and  frequentlv  accompanies  it.  Why,  in  a  given  case  of  hys- 
teria, symptoms  referable  to  the  ear  are  paramount,  can  be 
explained  onlv  on  the  ground  already  given  in  considering 
the  effects  of  neurasthenia — that  in  these  cases  the  ear  is  the 
point  of  least  resistance. 

Symptomatology. —  Impairment  in  hearing  varies  greatly 
in  degree,  but  is  usually  profound,  and  the  patient  may  be 
completely  deaf.  The  deafness  comes  on  suddenly,  as  a  rule, 
quite  frequentlv  as  the  result  of  some  severe  mental  shock, 
and  possesses  the  peculiar  characteristic  of  preserving  the 
original  degree  of  impairment  throughout  the  entire  history 


6o6     INFLUENCE    OF    FUNCTIONAL   NERVOUS    DISEASES. 

of  the  case.  The  condition  neither  improves  gradually  nor 
does  it  grow  worse.  Complete  restoration  of  function  may 
take  place  from  no  assignable  cause,  and  may  occur  quite  as 
suddenly  as  the  power  of  hearing  disappeared. 

Another  curious  symptom  is  the  so-called  transference  of 
the  lesion  from  one  side  to  the  other.  For  a  certain  length 
of  time  the  organ  of  one  side  alone  will  seem  to  be  perfectly 
deaf.  Suddenly  the  hearing  will  be  restored  upon  this  side, 
but  at  the  same  time  the  organ  of  the  opposite  side  becomes 
affected.  This  change  may  be  repeated  any  number  of  times. 
Pain  is  quite  commonly  complained  of  in  the  region  of  the 
ear,  it  being  located  either  decj)  in  the  meatus  or  in  the  mas- 
toid process.  Occasionally  this  pain  is  referred  to  the  phar- 
yngeal vault,  although  this  is  not  common.  Giddiness  and 
subjective  noises  are  usuallv  absent,  the  case  thus  presenting 
a  marked  contrast  from  one  dependent  upon  neurasthenia. 
Where  other  S3'mptoms  of  a  hysterical  nature  are  present, 
such  as  hcmiana3sthesia  or  hemiplegia,  the  defective  ear  is 
usually  on  the  side  of  the  body  jirescnting  the  sensory  or 
motor  impairment,  although  this  is  not  invariable. 

Diagnosis. — The  above  plienomcna  mav  be  observed  where 
to  all  appearances  the  organ  is  perfectly  healthy,  or  we  may 
find,  upon  examination,  evidences  of  a  preceding  suppurative 
or  nonsuppurative  process.  The  eye  alone  aids  us  very  little 
in  making  a  correct  diagnosis.  Much  information,  however, 
may  be  obtained  by  testing  the  sensitiveness  of  the  meatus 
and  drum  membrane  by  means  of  the  probe,  the  parts  being 
quite  frequently  ana:isthetic.  Functional  examination,  also, 
may  reveal  nothing  characteristic,  although  in  quite  a  num- 
ber of  cases  we  find  that  both  the  upper  and  lower  limits  of 
the  scale  are  poorly  perceived,  the  lower  tone  limit  being 
elevated,  while  interference  with  the  upper  tone  limit  seems 
to  be  more  common  than  with  the  Inwtr.  the  high  notes  be- 
ing but  poorly  heard,  as  a  rule.  This  reduction  of  the  upper 
tone  limit  is  distinct,  usuallv  extending  as  low  as  4  or  6  of  the 
Galton  scale. 

A  symptom  frequently  met  with  in  an  examination  is  the 
alternating  perception  of  the  high  notes  first  on  one  side  and 
then  on  the  other.  Upon  one  side  the  upper  tone  limit 
will  be  found  greatly  reduced,  while  the  organ  of  the  opj)o- 
site  side  will  perceive  the  highest  tones  of  the  scale  with 
ease.     On   repeating  the  experiment,  the  condition   will   be 


HYSTERIA— PROGNOSIS— TREATMENT.  607 

exactly  reversed,  and  this  alternation  mav  be  repeated  several 
times  durini]^  the  examination. 

The  occurrence  of  other  hysterical  manifestations  affords 
contirmatorv  evidence.  This  is  particularlv  true  if  the  field 
of  vision  is  investigated,  since  in  most  cases  this  is  uniformly 
contracted. 

Prognosis. —  It  is  absolutely  impossible  in  a  given  case  to 
render  an  intelligent  opinion  as  to  the  recovery  of  the  hearing. 
It  is  a  well-known  fact  that  in  hysteria  many  of  the  symptoms 
may  completely  disappear,  while  the  others  remain  unabated  ; 
and  we  also  note  that  interference  with  any  special  sense  is  a 
symptom  which  does  not  disaj^pear  readily. 

Treatment. — Those  drugs  administered  for  the  control  of 
hysteria  are  indicated  in  these  cases.  \'alerian,  either  in  the 
lorm  of  the  simple  tincture  or  the  ammoniatcd  tincture,  is 
olten  of  value.  The  same  is  true  of  asafotida,  the  bromides, 
various  preparations  of  zinc,  phosjihorus.  hyoscvamus,  galba- 
num.  etc. 

Hypnotic  treatment  is  probably  of  more  vrdue  in  these 
cases  than  any  other,  and  is  always  worthy  of  a  trial,  it 
should  never  be  forgotten  that  hysteria  is  a  disease,  and  that 
the  patient  is  not  malingering;  hence  severe  measures  arc 
worse  than  useless.  Curious  instances  have  been  reported 
of  the  complete  disappearance  of  the  deafness  upon  bringing 
a  magnet  close  to  the  ear.  By  this  same  means  it  has  also 
been  possible  to  transfer  the  condition  to  the  opposite  side. 


CHAPTER    XLIII. 

REFLEX   AURAL    DLSTURBANCES. 

A  PATHOLOGICAL  condition  in  any  portion  of  the  body 
mav  produce  within  the  organ  of  hearing,  not  only  alterations 
of  function,  but  also  certain  visible  changes.  While  we  are 
familiar  with  the  precise  mechanism  by  which  motor  reflexes 
are  brought  about,  those  of  a  sensory  or  trophic  character  are 
as  yet  obscure.  The  most  plausible  view  is,  that  under  the 
reflex  stimulus  certain  changes  take  place  in  the  vascular  sup- 
ply of  the  part  affected,  through  the  action  of  the  vasomotor 
nerves,  and  that  capillarv  dilatation  is  responsible  for  the  phe- 
nomena produced.  In  the  conducting  portion  of  the  organ  of 
hearing  the  deviations  from  the  normal  standard  are  of  such 
a  nature  as  to  be  visible  to  the  eve,  while  in  the  nervous  ap- 
paratus subjective  svmptoms  are  the  onlv  indication  of  anv 
change  from  the  standard  of  health.  Changes  which  take 
place  in  the  auricle  from  reflex  action  may  cause  an  abnormal 
redness  or  congestion  of  the  part  ;  or,  if  the  capillaries  are 
constricted,  the  blood  supply  will  be  diminished,  the  ear  ap- 
pearing pale  and  bloodless.  When  the  trophic  nerves  are  in- 
terfered with,  a  cutaneous  eruption  mav  occur,  the  most  cc^m- 
mon  of  which  is  herpes,  the  auricle  being  covered  bv  small 
vesicles  at  first  discrete,  but  by  coalescence  forming  bulla'. 
The  symptoms  have  alrcadv  been  described  bv  herpes  of  the 
auricle. 

Within  the  canal  a  circumscribed  external  otitis  mav  de- 
pend upon  a  reflex  cause,  the  pathological  lesion  producing  it 
being  most  frequently  a  corresponding  condition  upon  the 
opposite  side.  Hvpersensitive  areas  may  also  develop  in  the 
meatus,  usually  in  the  bony  portion  and  upon  its  floor,  the 
region  being  excessively  tender  to  the  touch  of  the  probe, 
while  ocular  inspection  either  reveals  no  deviation  from  the 
normal  condition,  or  only  a  minute  erosion  at  the  tender  point. 
In  some  instances  periodical   attacks  of    bleeding  from   the 

(608) 


TYMPANUM— PERCEPTIVE   MECHANISM.  609 

meatus  occur,  depending  upon  changes  in  some  remote  organ 
of  the  bodv. 

Within  the  tympanum  a  reflex  stimukis  may  cause  a  tran- 
sudation either  of  blood  or  serum  ;  in  either  case  the  quan- 
tity of  fluid  may  be  so  great  as  tcj  cause  ru{>ture  of  the  mem- 
brana  tympani.  Instances  of  otitis  media  of  a  reflex  character 
hayc  also  been  observed.  Pain  in  or  about  the  ear  in  a  yast 
majority  of  cases  depends  upon  some  local  inflammatory  pro- 
cess. It  is  occasionally  met  with  where  no  inflammatory  pro- 
cess presents  upon  the  most  careful  examination.  In  children 
particularly,  a  reflex  otalgia  often  occurs,  depending  either 
upon  the  eruption  of  the  molars  or  upon  early  dental  caries. 
This  latter  condition  is  occasionally  the  cause  of  an  inflamma- 
tory affection  of  the  middle  ear,  either  acute  or  chronic.  A 
symptom  of  rare  occurrence  is  a  periodical  oedema  oyer  the 
mastoid  process,  accompanied  by  exquisite  pain  and  tender- 
ness. I  haye  observed  one  instance  of  this  in  which  acute 
middle-ear  inflammation  was  complicated  by  this  angioneurotic 
nedema  ;  considerable  difficulty  was  exj)erienced  in  arriving  at 
a  correct  diagnosis,  and  the  question  of  the  advisability  of  open- 
ing the  mastoid  was  seriously  debated.  All  reflex  disturb- 
ances, particularly  those  of  a  painful  character,  are  most  fre- 
qucnth'  met  with  in  females  of  a  neurotic  or  hysterical  type. 

When  we  come  to  consider  the  perce{)live  tract,  cases  of 
ana?sthesia  or  para^sthesia  are  by  no  means  imcommon.  A 
moderate  impairment  of  hearing  may  be  the  result  of  visceral 
disturbances,  jiarticularlv  of  the  pelvic  viscera,  while  tinnitus 
resulting  from  constij)ation.  subacute  gastritis,  a  pathological 
condition  within  the  pelvis,  etc.,  is  of  common  occurrence. 
An  interference  with  the  statical  function  of  the  ear  is  proba- 
bly the  most  familiar  example  of  reflex  excitation  of  the 
auditory  perceptive  apparatus.  The  giddiness  so  common  in 
disorders  of  digestion  is  without  doubt  dependent  u[)on 
stimuli  conveyed  to  the  auditory  nucleus  in  the  medulla 
through  the  vagus  nerve,  the  vagus  centre  lying  close  to  the 
nucleus  of  the  vestibular  nerve.  It  is  probable  that  here  the 
condition  is  one  of  increased  vascularity  from  capillary  dilata- 
tion. Reasoning  in  this  manner,  we  are  able  to  explain  irreg- 
ular attacks  of  impairment  in  the  hearing  of  short  duration, 
accompanied  by  intense  subjective  noises,  by  supposing  that 
a  similar  disturbance  has  taken  place  either  in  the  medullary 
centre  of  the  cochlear  nerve  or  in  the  cortical  auditor}'  cen- 
41 


^jQ  REFLEX    AURAL    DISTURBANCES. 

tie  itself.  The  symptom  which  leads  us  to  suspect  that  any 
functional  disturbance  of  the  ear  is  dependent  upon  a  reflex 
cause  is  the  irregular  appearance  of  the  symptoms,  and  their 
sudden  and  complete  subsidence,  often  from  no  apparent 
cause.  Structural  changes  necessitate  a  certain  permanency 
of  the  manifestation  ;  and  where  this  does  not  occur  we  can 
onlv  explain  the  condition  by  supposing  that  the  centres  have 
been  irritated  by  a  temporary  increase  in  the  blood  supply. 

If  now  a  thorough  examination  of  the  patient  reveals  a  re- 
mote lesion,  particularly  if  it  is  located  in  a  region  where  or- 
tranic  changes  are  prone  to  excite  reflex  symptoms,  we  should 
bear  in  mind  that  such  reflex  sympt(Mns  may  be  cpiite  as  well 
referred  to  the  organ  of  hearing  as  to  any  other  portion  of  the 
body.  We  can  not  too  strongly  emphasize  the  necessity  of  a 
thorough  physical  examination  in  every  obscure  case  ;  in  other 
words,  the  otologist  should  locate  subjective  phenomena  in 
the  ear  rather  by  exclusion  than  otherwise. 

We  have  already  spoken  of  those  regions  of  the  body  where 
any  specific  change  is  particularly  liable  to  exert  a  reflex  in- 
fluence upon  either  the  centres  of  audition  or  the  terminal 
apparatus  of  the  auditory  nerve.  To  this  list  we  must  add  the 
opposite  ear,  since  lesions  of  an  inflammatory  character,  or  in- 
juries to  the  organ  of  one  side,  may  produce  not  only  tcinpo- 
rary  but  often  permanent  changes  in  the  opposite  organ. 
The  augmentation  of  the  perceptive  power  observed  when 
the  opposite  organ  of  hearing  is  subjected  to  sonorous  vi- 
brations has  already  been  alluded  to.  Another  familiar  ex- 
ample is  the  effect  of  condensing  the  air  in  the  auditcjry 
meatus,  while  at  the  same  time  a  sounding  body  is  held  close 
to  the  opposite  ear.  If  this  experiment  is  tried,  we  find  that 
the  sudden  condensation  of  air  diminishes  the  perceptive 
power  of  the  opposite  organ.  Here  it  is  supposed  that  the 
path  of  the  reflex  current  lies  through  the  upper  portion  of 
the  cervical  cord,  and  the  test  is  used  to  demonstrate  the 
integrity  of  this  portion  of  the  central  nervous  system.  The 
experiment  is  of  much  greater  value  from  a  clinical  point  of 
view  in  explaining  the  occurrence  of  subjective  noises  re- 
ferred to  one  side,  in  which  an  examination  of  the  ear  reveals 
nothing  abnormal.  Examination  of  the  opposite  side  fre- 
quently reveals  either  a  narrowing  of  the  Eustachian  canal, 
the  presence  of  impacted  cerumen,  or  a  marked  pathological 
process  within  the  tympanum,  and  the  subjective  symptoms 


DIAGNOSIS-PROGNOSIS— TREATMENT.  6i  I 

do  not  disappear  until  the  pathological  condition  in  the  op- 
posite car  is  removed. 

Diagnosis. — The  recognition  of  the  reflex  nature  of  these 
symptoms  then  depends  upon  their  occurrence  in  an  appar- 
ently healthy  organ,  and  next  upi^n  the  discovery  oi  some 
remote  pathological  condition  which  may  act  as  an  exciting 
cause.  A  valuable  confirmatory  sign  is  that  afforded  by  an 
examination  with  the  galvanic  current,  a  condition  of  marked 
hyperesthesia  usually  being  found.  If  we  can  exclude  with 
certainty  an  active  process  within  the  middle  car  or  within 
the  cranium  itself,  the  auditory  hyperaisthesia  must  be  reflex  ; 
and  if  the  cause  docs  not  lie  in  the  opposite  car  a  remote  lesion 
alone  can  explain  it. 

Prognosis. — Our  ability  to  correct  these  reflex  disturb- 
ances tlcpends  not  only  ui)on  the  amenability  of  the  ])rimary 
exciting  cause  to  treatment,  but  also  upon  the  duration  of  the 
afTection  before  the  patient  comes  under  observation.  The 
])ersistcnt  excitation  of  the  perceptive  centres  directly,  or  in- 
directly through  the  end  organ  of  the  nerve,  may  elTect  changes 
w  hicii  will  rcuKiin  after  the  exciting  cause  has  been  removed. 
Where  the  case  is  observed  early  and  depends  upon  a  re- 
movable cause,  the  results  of  treatment  are,  as  a  rule,  favorable. 

Treatment.  (  )ui-  first  object  when  a  case  lA  this  character 
[)resents  for  treatment  is  to  relieve  the  aural  symptoms  from 
which  the  j^atient  is  sulTering,  without  reference  to  the  causa- 
tion. I'nless  this  cause  is  manifest,  much  valuable  lime  is 
wasted  in  searching  for  the  atiological  feature.  The  percep- 
tive tract  is  in  a  state  of  constant  hyperajsthesia,  which  from 
its  long  duration  may  be  difficult  to  overcome  after  the  excit- 
ing cause  has  disappeared.  Undoubtedly  the  drug  which  ex- 
erts the  most  influence  in  these  cases  is  bromide  of  sodium,  or 
its  equivalent,  hydrobromic  acid.  By  the  administration  of 
these  remedies  the  receptive  centres  are  rendered  less  sensi- 
tive to  the  action  of  stimuli.  The  efl'cct  is  similar  to  that  ob- 
tained when  a  broken  limb  or  strained  joint  is  placed  in  a 
fixation  apparatus;  the  nervous  tissues  are  put  completely  at 
rest,  so  to  speak,  by  rendering  them  insensible  to  the  action 
of  the  stimulus.  Our  next  effort  should  be  to  discover  the 
cause  of  the  affection  :  this  can  only  be  done  by  a  thorough 
investigation  of  the  history  of  the  case — not  only  the  history 
of  the  disease,  but  one  calculated  to  elicit  all  facts  of  medical 
or  surgical  interest  throughout  the  entire  course  of  the  pa- 


gj2  REFLEX    AURAL   DISTURBANCES. 

tient's  life.  An  injury  received  in  childhood  and  entirely  for- 
gotten may  have  set  in  play  forces,  which  in  adult  years  have 
produced  the  symptoms  complained  of.  The  age  of  the  pa- 
tient is  to  be  borne  in  mind,  particularly  in  the  case  of  females, 
since  the  period  about  the  menopause  is  a  time  at  which  these 
symptoms  are  particularly  prone  to  make  their  appearance. 
The  habit  of  life,  the  occupation,  and  all  facts  which  may 
directly  or  indirectly  exert  an  influence  upon  the  nervous 
tone  of  the  body,  should  be  carefully  investigated.  Several 
factors  may  present  as  a  possible  cause  of  the  aural  disturb- 
ance, and  time  is  necessary  for  the  thorough  elimination  of 
the  unimportant  ones.  It  should  always  be  borne  in  mind 
that  these  cases  are  among  the  most  troublesome  that  we 
have  to  treat,  and  may  for  a  long  time  be  irresponsive  to  all 
our  efforts.  It  is  only  by  the  process  of  exclusion  that  the 
exact  aetiological  feature  can  be  discovered,  after  which  its 
correction  is  usually  a  matter  of  comparative  simplicity. 

Diathetic  conditions,  particularly  gout  and  rheumatism, 
may  have  manifested  themselves  previously  in  no  other  man- 
ner, and  the  symptoms  referable  to  the  organ  of  hearing  may 
be  the  first  intimation  of  the  presence  of  such  conditions.  The 
history  of  heredity  in  such  a  case  is  the  only  clew  to  guide  us 
to  the  discovery  of  the  cause  operative  in  the  production  of 
symptoms. 

Where  bromides  fail  to  control  the  reflex  })henomena,  hy- 
oscyamus,  either  in  the  form  of  the  tincture  or  in  the  form  of 
the  alkaloid — hyoscyamine — may  serve  an  efficient  purpose. 
Under  no  circumstances  should  morphine  be  administered, 
since  it  is  easy  for  the  patient  to  acquire  the  opium  habit  if 
this  practice  is  once  begun.  The  various  antispasmodics, 
such  as  asafoetida,  valerian,  galbanum,  etc.,  are  of  use  in  cer- 
tain cases,  and  indications  for  their  administration  are  usually 
sufficiently  clear.  Where  the  symptoms  have  persisted  for  a 
long  time  and  there  are  evidences  of  vascular  dilatation,  the 
Huid  extract  of  ergot,  in  doses  of  fifteen  to  twenty  minims, 
three  times  daily,  exerts  a  beneficial  action. 

Symptoms  of  venous  congestion  dependent  upon  imperfect 
cardiac  action  demand  the  use  of  stimulants.  Of  these,  strych- 
nine is  probably  the  best,  provided  no  organic  lesion  is  pres- 
ent. If  the  disturbance  of  circulation  is  only  moderate,  the 
use  of  a  certain  amount  of  an  alcoholic  stimulant  dailv  is  a 
valuable  means  of  effecting  the  desired  change.     In  asthenic 


TREATMENT.  613 

cases,  particularly  where  the  patient  has  sufTercd  from  over- 
work, the  addition  of  a  moderate  amount  of  wine  to  the 
dietary  is  followed  frequently  by  happy  results;  the  desired 
stimulating  result  is  thus  obtained  without  resorting  to  the 
administration  of  drugs.  In  cases  where  ana?mia  is  coinci- 
dent, naturally  this  condition  must  be  treated  on  general 
medical  principles;  and  the  same  is  true  of  the  management 
of  those  cases  where  there  is  a  plethoric  intracranial  con- 
dition. 


CHAPTER   XLIV. 

DEAF-MUTISM. 

The  loss  of  audition  in  the  early  years  of  life,  or  the  ab- 
sence of  this  special  sense  as  a  cong^enital  defect,  invariably 
leads  to  mutism.  It  is  manifestly  difficult  to  determine  in 
many  cases  whether  the  power  of  sound  perception  has  been 
destroyed  by  some  disease  in  infancy  or  has  been  absent 
from  birth.  Practically  the  question  is  one  of  but  little  im- 
portance, as  each  case  must  present  features  peculiar  to  itself. 

iEtiology. — Heredity  seems  to  play  an  important  part  in 
the  causation  of  conf^enital  deaf-mutism.  Several  members 
of  the  same  family  are  frequently  affected,  although  direct 
transmission  is  rather  infrequent,  the  offspring  of  parents 
afflicted  with  the  malady  as  a  rule  escaping.  Consanguinity 
of  the  parents  is  among  the  most  common  of  the  causes,  and 
the  greater  frequency  of  deaf-mutism  among  the  inhabitants 
of  mountainous  districts  is  probably  to  be  explained  by  the 
fact  that  intermarriage  is  much  more  common  among  such 
people.  The  station  of  life  exerts  very  little  influence  upon 
the  congenital  form  of  the  disease.  Defective  mental  devel- 
opment  is  not,  as  a  rule,  associated  with  a  congenital  defect 
in  audition,  and  in  many  suffering  from  the  loss  of  this  special 
sense  the  mental  faculties  seem  to  be  developed  beyond  the 
normal  standard.  Hereditary  specific  disease  is  a  causative 
factor  in  certain  cases. 

Occasionally  the  affection  seems  attributable  to  influences 
during  intra-utcrine  life,  such  as  a  severe  mental  shock  to  the 
mother,  or  some  physical  injury. 

Among  the  causes  which  lead  to  acquired  deaf-mutism 
may  be  mentioned  mjuries  to  the  head  during  labor  or  in 
early  infancy  ;  the  acute  infectious  diseases,  leading  to  involve- 
ment of  the  perceptive  tract,  cither  primarily  or  as  a  result 
of  a  preceding  middle-ear  inflammation  ;  acute  and  chronic 
inflammatory  conditions  within  the  cranium  ;  adenoid  vegeta- 

(6i4) 


PATHOLOGY. 


6,5 


tions,  causing  a  chronic  congestion  of  the  middle  ear  and 
labyrintli  as  well,  the  chronic  hvpera?mia  of  the  middle  ear 
leading  to  repeated  attacks  of  acute  catarrhal  otitis  in  infancy. 
The  precise  manner  in  which  the  organ  of  hearing  is  affected 
in  these  diseases  has  already  been  dilated  upon  in  the  preced- 
ing chapters,  and  need  not  be  repeated  here.  It  is  enough  to 
remember  that  any  affection  of  the  conducting  or  perceiving 
mechanism  which  is  sufficiently  extensive  to  cause  profound 
impairment  of  hearing  will  lead  to  deaf-mutism  if  it  occurs 
in  the  early  vears  of  life,  before  the  child  has  acquired  the 
power  of  articulate  speech.  Even  in  children  of  four  years  of 
age,  who  can  speak  fairly  well,  the  loss  of  the  sense  of  hearing 
is  often  followed  by  mutism,  the  patients  forgetting  the  few 
words  which  they  have  learned.  This  occurs  almost  invari- 
ably, unless  special  attention  is  directed  toward  its  preven- 
tion. In  older  children  the  loss  of  audition  is  not  necessarily 
followed  bv  mutism. 

Pathology. — The  congenital  absence  of  some  essential  por- 
tion (»t  the  conducting  mechanism  has  been  found  in  a  num- 
ber of  cases  which  have  been  investigated  post  mortem.  In 
s|)eaking  of  deformities  of  the  auricle,  mcnti(^n  was  made  of 
the  fre(]uent  absence  of  the  bonv  meatus  in  those  cases,  and  of 
the  almost  invariable  malformation  or  absence  of  the  deeper 
portions  of  the  conducting  mechanism  in  cases  of  congenital 
atresia  of  the  canal.  Acquired  atresia  of  the  meatus,  if  occur- 
ring in  very  early  life,  might  also  lead  to  deaf-mutism,  Intra- 
tymjKuiic  changes  preventing  vibration  of  the  labyrinthine 
fluid  have  also  been  found  in  certain  instances.  Occlusion 
of  the  round  and  oval  windows,  either  as  a  congenital  defor- 
mity or  as  the  sequel  to  a  pathological  process  in  early  life, 
constitutes  the  lesion  in  some  cases. 

A  congenital  defect  or  an  acquired  lesion  in  the  labyrinth, 
auditory  nerve  trunk,  or  in  the  nuclei  of  origin,  fibres  of  com- 
munication, or  cortical  areas,  constitute  briefly  the  anatomical 
characteristics  of  cases  resulting  from  interference  with  the 
perceptive  mechanism. 

Among  the  secondary  changes  may  be  mentioned  the 
lack  of  development  in  the  vocal  organs  from  prolonged  dis- 
use. In  cases  presenting  a  lesion  of  the  conducting  mechan- 
ism  sufficient  to  account  for  the  absence  of  audition,  it  is 
probable  that  the  changes  in  the  perceptive  tract  may  be  due 
to  the  same  cause. 


6i6  DEAF-MUTISM. 

Symptomatology. —  In  very  young  children  who  have 
never  spoken,  the  first  symptom  noted  is  usually  the  failure 
to  acquire  the  power  of  articulate  speech.  Attention  is  then 
directed  to  the  ears,  and  it  is  discovered  that  the  auditory 
sense  is  also  wanting.  In  older  children,  the  failure  to  re- 
spond when  spoken  to  and  the  gradual  appearance  of  mutism 
declare  the  nature  of  the  affection.  In  these  older  cases  the 
hearing  may  not  be  entirely  lost  at  first,  and  as  the  patient 
seems  to  hear  loud  sounds,  parents  often  neglect  the  condi- 
tion until  it  is  too  late  to  prevent  deaf-mutism. 

Diagnosis. — Since  the  age  at  which  children  acquire  the 
power  of  articulate  speech  varies  greatly,  and  as  the  same  is 
true  of  the  age  at  which  the  infant  responds  to  stimulation  of 
the  organ  of  hearing,  it  is  often  difficult  to  determine  whether 
or  not  a  child  is  deaf  or  whether  the  development  of  the 
special  sense  is  dchiyed  simply.  With  a  history  of  any  pre- 
vious intracranial  disease  or  any  evidence  upon  ocular  in- 
spection of  an  abnormity,  congenital  or  acquired,  of  the  organ 
of  hearing  there  is  naturally  a  strong  suspicion  that  the  con- 
ditions are  interdependent.  When  the  child  has  learned  a  few 
words  and  fails  to  advance,  tiie  diagnosis  naturallv  {^resents 
no  difificulties.  It  is  certainly  unsafe  to  give  any  other  than  a 
guarded  prognosis  in  patients  imder  eighteen  months  of  age. 

Even  very  young  children  should  be  carefully  tested  as  to 
their  ability  to  perceive  sounds  varying  in  intensity  and  pitch. 
Tuning  forks  of  low  and  higii  pitch  furnish  a  convenient  means 
of  determining  the  probable  presence  of  even  a  slight  amount 
of  audition.  The  forks  should  be  set  in  vibration  and  held 
first  before  the  ear,  the  attention  of  the  child  being  diverted 
from  the  movements  of  the  examiner.  If  the  fork  is  heard,  the 
little  patient  will  usually  give  evidence  of  the  fact,  cither  by 
turning  toward  the  source  of  sound,  or  there  will  be  a  change 
in  facial  expression  which  will  be  easily  recognizable.  If  there 
is  any  doubt,  the  experiment  may  be  repeated  and  the  fork  be 
held  near  the  ear  without  being  set  in  vibration.  In  the  same 
manner  bone  conduction  should  be  tested,  the  vibrating  fork, 
and  the  same  instrument  in  a  state  of  rest  being  brought  alter- 
nately in  contact  with  the  head.  The  Galton  whistle  should 
also  be  employed,  and  even  in  voung  children  it  is  sometimes 
possible  to  obtain  the  limits  of  audition  with  fair  accuracy. 

Clapping  the  hands  behind  the  child's  head,  snapping  the 
fingers,  etc.,  are  also  tests  which  may  be  of  use  ;  but  my  own 


PROGNOSIS— TREATMENT.  617 

experience  has  been  tliat  the  tuning  fork  and  Galton  whistle 
w  ill  furnish  the  desired  information. 

Prognosis. — This  is  necessarily  grave.  Politzer*  consid- 
ers that  the  prognosis  is  better  in  the  congenital  than  in  the 
acquired  cases.  Certainly  in  those  of  congenital  origin  an 
unfavorable  opinion  should  not  be  given  in  very  early  life,  as 
the  special  senses  may  develop  later.  In  the  cases  which 
follow  anv  affection  in  early  infancy,  the  nature  of  the  disease 
which  produced  the  aural  affection,  the  extent  of  the  local 
process,  and  the  length  of  time  which  has  elapsed  before  the 
patient  comes  under  observation,  all  influence  the  prognosis. 

Treatment. — When  the  malady  depends  upon  a  known 
cause  the  indications  for  treatment  will  be  clear.  In  all  cases 
presenting  a  condition  which  could  give  rise  to  the  profound 
impairment  this  should  be  removed.  In  young  children  the 
presence  of  adenoid  vegetations  should  be  determined,  and  if 
the  drum  membranes  are  intact  anv  mass  of  this  kind  should 
be  removed.  In  the  same  manner  the  history  of  an  attack  of 
ej)idemic  cerebro-spinal  meningitis  or  of  an  affection  which 
could  induce  a  labyrinthine  inflammation  should  be  an  indi- 
cation for  the  use  of  the  proper  therapeutic  measures.  A 
thorough  examination  should  always  be  made,  but  if  no  indi- 
cations arc  found  for  any  particular  plan  of  treatment,  the  sur- 
geon should  remember  that  therapeutic  measures  are  useless 
in  manv  cases  and  that  valuable  time  may  be  lost.  If  there  is 
no  indication  for  anv  one  plan  of  treatment,  the  child  should 
at  once  be  placed  in  the  hands  of  those  who  make  the  educa- 
tion of  such  patients  a  life  studv.  It  is  rare  in  anv  case  which 
comes  imder  observation  during  childhood  to  find  a  com- 
plete absence  of  the  auditory  function,  and  by  proper  train- 
ing this  mav  be  much  improved.  The  best  results  are  ob- 
tained by  those  methods  which  stimulate  the  portion  of  the 
perceptive  tract  which  remains  bv  the  use  of  the  human 
voice,  the  sound  being  conveved  to  the  ear  through  a  proper 
instrument,  and  by  education  render  it  capable  of  supph  ing 
the  place  of  the  perfect  organ  of  hearing.  It  is  surprising 
how  much  can  be  gained  if  these  children  come  under  ob- 
servation at  an  early  period,  and  when  we  have  decided  that 
nothing  can  be  done  to  relieve  the  condition  it  is  our  duty  to 
urge  their  education  in  this  manner. 

*  Diseases  of  the  Ear,  American  edition,  1894,  p.  706. 


DISEASES   OF   THE   NOSE   AND  NASO-PHARYNN. 

It  is  necessary  to  consider,  in  connection  with  the  ear, 
certain  affections  of  the  upper  air  passages  which  either  have 
been  operative  in  the  production  of  the  aural  condition,  or 
still  exert  a  marked  influence  upon  it.  The  principal  affec- 
tions under  this  head  will  be  considered  briefly,  and  more 
with  reference  to  their  treatment  than  to  the  special  symp- 
toms which  they  produce. 

We  may  classify  affections  of  the  upper  air  passages  which 
come  under  this  head  as  hypertrophic  and  atrophic.  The 
first  condition  interferes  with  the  circulation  within  the  tym- 
panum and  labyrinth,  and  also  disturbs  the  equilibrium  of 
the  drum  membrane  and  ossicles  by  interfering  with  the 
free  ventilation  of  the  tympanic  cavity.  Atrophic  changes, 
on  the  other  hand,  are  much  less  frequently  operative  in  the 
production  of  aural  svmptoms.  Occasionally  thev  represent 
the  results  of  a  previous  inflammatorv  condition  which  has 
caused  the  aural  affection,  but,  at  the  time  when  the  atrophic 
changes  are  observed,  exert  but  little  influence  upon  the  con- 
dition of  the  ear.  The  slight  effect  which  they  produce  is 
mechanical,  and  depends  upon  the  efforts  of  the  patient  in 
relieving  the  mucous  membrane  of  accumulations  of  inspis- 
sated secretion  dependent  upon  its  atrophied  condition.  All 
these  movements  of  the  pharynx  affect  the  calibre  of  the 
Eustachian  tube  and  interfere  with  the  atmospheric  pressure 
within  the  tympanum. 

Anatomically  we  shall  consider — 

1.  Diseases  of  the  nasal  cavitv. 

2.  Diseases  of  the  naso-pharynx. 

Under  diseases  of  the  nasal  passages  we  have  belonging 
to  the  group  characterized  bv  the  presence  of  ncwlv  formed 
tissue,  hypertrophic  rhinitis  and  deformities  of  the  nasal  sep- 
tum. An  atrophic  condition  of  the  mucous  membrane  lining 
the  nasal  cavity  is  more  rare,  and  constitutes  the  disease 
known  as  atrophic  rhinitis. 

(618) 


DISEASES    OF    THE    NOSE    AND    NASO-PHARYNX.        619 

In  the  naso-pliaiynx  the  most  common  hypertrophic  con- 
dition is  that  known  as  adenoid  vegetations,  or  enlargement 
of  the  pharyngeal  tonsil.  Neoplasms  will  not  be  considered 
here,  since  the  aural  symptoms  to  which  they  give  rise  are 
always  secondary  to  those  referred  to  the  region  from  which 
the  growth  springs.  An  atrophic  condition  of  the  naso-phar- 
yngeal  mucous  membrane  constitutes  the  lesion  in  so-called 
naso-pharyngeal  catarrh. 


CHAPTER    XLV. 

HYPERTROPHIC    RHINITIS.— DEFORMITIES   OF   THE   NASAL 

SEPTUM. 

HVPERTROl'HR     RHINITIS. 

This  condition  consists  in  a  true  hypertrophy  of  the  ele- 
ments which  go  to  make  up  the  turbinated  bodies,  and  in- 
^volves  especially  the  inferior  turbinated  body.  In  addition 
.to  the  new  growth  of  connective  tissue  present,  the  venous 
sinuses  inclosed  between  its  meshes  become  tortuous,  and 
increase  in  size  and  in  number.  As  a  result  of  these  changes, 
the  tissue  covering  the  inferior  turbinated  bone  is  increased 
in  volume,  and  in  marked  cases  hangs  loosely  from  its  bony 
attachment,  so  as  to  obstruct  the  nostril  to  a  considerable 
degree.  When  the  venous  channels  pre  engorged  with 
blood,  this  obstructing  mass  may  attain  such  a  size  as  to 
completely  close  the  inferior  meatus  and  prevent  the  passage 
of  air.  The  condition  probablv  depends  most  frequently, 
according  to  Bosworth,  upon  a  deformity  of  the  nasal  sep- 
tum, and  is  most  marked  upon  the  side  which  is  least  ob- 
structed by  the  septal  projection.  Owing  to  the  obstruction 
of  the  opposite  nostril,  each  act  of  insi)irati()n  rarefies  the  air 
in  the  opposite  nasal  chamber  and  favors  dilatation  of  the 
veins  imbedded  in  the  turbinated  tissue.  Continued  for  a 
long  time,  permanent  tissue  changes  take  place,  resulting  in 
the  chronic  venous  engorgement,  and  in  the  hvj^crtrophic 
tissue  changes  above  enumerated.  Such  a  condition  renders 
the  patient  extremely  susceptible  to  variations  in  temperature, 
which  result  in  the  affection  commonly  known  as  "cold  in 
the  head."  Repeated  attacks  of  this  character  operate  to 
increase  the  chronic  condition  which  underlies  it.  Without 
either  entering  into  an  enumeration  of  the  various  reflex  dis- 
turbances depending  upon  this  nasal  condition,  or  dwelling 
upon  the  various  local  symptoms  which  are  caused,  we  may 
state  that  the  most  common  symptom  of  which  the  sufferer 
complains  is  the  inability  to  breathe  through  the  nose,  and  of 

(6ao) 


EFFECT   OF   OBSTRUCTIVE    CONDITIONS.  62 1 

frequently  repeated  colds  in  the  head.  The  effect  of  these 
attacks  of  nasal  stenosis  may  influence  the  hearing  to  a 
marked  degree.  Patients  almost  invariably  state  that  during 
such  an  attack  the  hearing  is  much  less  acute  than  when  the 
nasal  respiration  is  not  interfered  with,  and  that,  as  the  at- 
tacks increase  in  frequency,  complete  restoration  of  the  hear- 
ing does  not  take  place  as  readily.  The  intervals  during 
which  the  hearing  is  fairly  good  become  shorter  and  shorter, 
until  every  fresh  attack  seems  to  leave  the  power  of  audition 
more  impaired.  While  many  of  these  symptoms  depend 
upon  interference  both  with  the  circulation  within  the  tym- 
panum and  the  Eustachian  tube,  and  with  the  proper  ventila- 
tion of  the  middle  car,  it  is  certain  that  a  large  proportion  of 
cases  are  met  with  in  which  a  physical  examination  reveals 
the  Eustachian  tube  patent  throughout  the  entire  attack,  and 
in  these  cases  we  must  conclude  that  the  turgcsccnce  of  the 
turbinated  bodies  interferes  with  the  venous  return  current 
from  the  labyrinth,  causing  labyrinthine  congestion.  Func- 
tional examination  of  these  patients  seems  t(^  confirm  this 
view,  and  it  is  therefore  important  to  remember  that  the 
venous  engorgement  within  the  nasal  j)assages  is  oj)erative 
in  the  i)roduction  t)f  labyrinthine  symptoms  directly,  as  well 
as  in  exciting  changes  in  the  tympanic  cavity. 

This  is  undoubtedly  the  reason  why,  in  many  cases,  sub- 
jective noises  will  be  improved  by  treating  the  upper  air  pas- 
sages, although  upon  fimctional  examination  the  patients 
exhibit  none  of  tiie  phenomena  characteristic  of  an  involve- 
ment of  the  conducting  mechanism.  The  symptoms  are, 
without  doubt,  due  to  vascular  changes  within  the  labyrinth 
dependent  upon  the  turgescence  of  the  turbinated  tissue 
within  the  nasal  cavity,  and  a  removal  of  the  cause  relieves 
the  symptoins.  This  fact  certainly  broadens  the  field  of  use- 
fulness of  intranasal  surgery,  which  has  quite  commonly  been 
supposed  to  be  of  value  only  in  affections  of  the  middle  ear. 
Symptoms  referable  to  the  nasal  passages  themselves  have 
already  been  alluded  to,  while  a  more  detailed  account  of  the 
various  aural  symptoms  will  be  found  under  the  different 
diseases  before  described. 

Concerning  the  diagnosis  of  the  condition,  an  examination 
both  by  anterior  and  posterior  rhinoscopy  will  render  its 
recognition  easy.  Upon  anterior  rhinoscopic  examination, 
the  inferior  turbinated  body  will  be  seen  to  project  into  the 


^^2  HYPERTROPHIC    RHINITIS. 

passage,  occluding  it  more  or  less  completely  and  preventing 
an  inspection  of  the  posterior  wall  of  the  pharyngeal  vault 
through  the  anterior  nares.  Where  a  deformity  of  the  sep- 
tum is  present,  the  hypertrophy  will  be  found  more  marked 
upon  the  side  opposite  to  that  occluded  by  the  septal  obstruc- 
tion. Curiously  enough,  the  patient  will  complain  of  this 
nostril  as  the  one  obstructed,  the  reason  being  that  respira- 
tion  through  the  opposite  passage  having  been  imperfect  for 
a  long  time,  he  has  ceased  to  observe  changes  in  its  patency, 
while  the  obstruction  upon  the  opposite  side,  or  the  one  upon 
which  he  depends  for  nasal  respiration,  is  immediately  recog- 
nized, as  any  increased  turgcsccnce  practically  renders  nasal 
respiration  impossible.  Impact  with  a  i)robe  temporarily  ex- 
presses the  blood  from  the  swollen  turbinated  tissue,  the 
engorged  condition  immediately  recurring  as  soon  as  me- 
chanical pressure  is  removed.  This  examination  with  a 
probe  also  reveals  to  the  operator  that  the  membrane  is 
thickened  ;  it  feels  velvety  to  the  touch  as  the  probe  presses 
it  against  the  outer  bony  wall  of  the  nasal  cavity.  Posterior 
rhinoscopy  will  reveal  a  similar  condition  over  the  posterior 
extremity  of  the  lower  turbinated  body,  and  in  some  instances 
the  hypertrophic  changes  may  be  more  marked  here  than  an- 
teriorly. The  posterior  extremity  of  the  inferior  turbinated 
body  mav  project  into  the  cavity  of  the  naso-pharynx  as  a 
round  mass,  completely  occluding  the  choana  of  the  afTected 
side.  Occasional! V,  instead  of  presenting  a  smooth  contour, 
the  surface  of  the  mass  is  irrcgularlv  mammillatcd.  This 
constitutes  the  so  called  posterior  hvpertroj)hy,  and  may  be 
present  upon  both  sides. 

The  middle  turbinated  body  mav  present  evidences  of 
hypertrophv,  but  less  extensive  usuallv  than  those  exhibited 
by  the  inferior. 

If  a  ten-per-cent  solution  of  cocaine  is  sprayed  into  the 
anterior  nares,  and  the  parts  again  examined  after  a  few  min- 
utes, a  marked  change  will  be  observed.  Owing  to  the  ac- 
tion of  the  drug,  the  venous  engorgement  will  have  disapi- 
peared,  the  mucous  membrane  will  be  seen  to  apply  itself 
more  closel}'  to  the  bonv  parts  beneath,  and  the  passage  will 
be  correspondingl}^  more  patent.  The  posterior  pharyngeal 
wall  will  be  readily  seen  in  most  instances,  if  the  head  of  the 
patient  is  held  in  such  a  position  that  the  floor  of  the  nasal 
cavity  is  horizontal.     In   order  to  render  this   inspection  of 


TREATMENT. 


623 


the  posterior  wall  possible,  the  tip  of  the  nose  must  be  tilted 
up  strongly,  and  the  operator  must  so  direct  the  rays  of  light 
that  the  deepest  portion  of  the  passage  will  be  thoroughly 
illuminated.  The  light  reflex  of  the  posterior  pharyngeal 
wall  will  then  be  seen,  its  recognition  being  more  easy  if  the 
patient  is  asked  to  pronounce  the  letter  /•,  thus  eleyatiiig  the 
soft  palate.  During  this  act  the  leyator  palati  muscle  will 
be  seen  to  pass  across  the  field  of  yision,  encroaching  upon 
the  posterior  nasal  orifice. 

The  results  of  treatment  of  this  condition  are  exceedingly 
satisfactory,  and  it  will  be  always  possible  not  (jnly  to  relieye 
the  attacks  of  intermittent  turgesccncc  of  the  mucous  mem- 
brane, but  also  to  cause  the  absorption  of  hyperplastic  tissue 
and  to  return  the  membrane  to  its  normal  condition.  Our 
efforts  at  treatment  must  be  directed  both  to  the  results  of 
the  hyperplastic  process  and  toward  the  rcmoyal  of  those 
causes  which  operate  to  produce  the  intermittent  turgcscence 
of  the  membrane. 

If  there  is  an  obstruction  upon  one  side  due  to  a  deform- 
it\  of  the  nasal  septum,  this  must  first  receive  attention. 
The  particular  manner  in  which  this  shall  be  done  will  de- 
l>end  upon  the  choice  of  the  iiuliyidual  ojierator,  and  some- 
what upon  the  character  of  the  obstruction.  Where  a  j)rom- 
inent  ridge  is  present  this  is  best  remoyed  by  means  of  the 
nasal  saw.  Where  the  sej)tal  obstruction  is  not  sufliciently 
circumscribed  to  admit  of  removal  in  this  manner,  it  may  be 
burned  away  by  means  of  the  galyano-cautery.  Some  j»refer 
the  use  of  the  electric  trephine,  and  good  residts  undoubt- 
edly f(jllow  the  use  of  this  instrument,  but  the  author  has 
had  no  personal  ex{)erience  with  it.  For  the  relief  of  the 
turbinate  hypertrophy  the  membrane  should  first  be  exsan- 
guinated by  means  of  cocaine,  after  which  a  small  bead  (;f 
chromic  acid  melted  upon  the  tip  of  a  metal  probe  should  be 
applied  to  a  limited  area  over  the  inferior  turbinated  body. 
The  site  of  the  application  should  correspond  to  that  which 
was  tnost  prominent  before  cocaine  was  applied.  The  super- 
ficial extent  of  this  application  will  depend  upon  the  degree 
of  the  previous  turgcscence  ;  usually  the  membrane  is  cov- 
ered with  the  chromic  acid  over  an  area  about  the  size  of  a 
split  pea.  Care  should  be  taken  to  dry  the  nasal  mucous 
membrane  with  a  pledget  of  cotton  before  applying  the 
chromic  acid  ;  any  excess  of  acid    is  to  be  immediately  re- 


624  DEFORMITIES   OF    THE    NASAL    SEPTUM. 

moved  bv  means  of  a  dry  pledget  of  cotton,  to  prevent  its 
spreading  over  the  surface  of  the  membrane.  The  result  of 
this  application  is  to  form  an  inelastic  eschar,  which  pre- 
vents  the  swelling  of  the  turbinated  tissue  after  the  effect  of 
the  cocaine  has  passed  away.  The  blood  vessels  are  thus 
supported,  and  their  walls  resume  their  normal  tone.  The 
slough  separates  at  the  end  of  from  five  to  ten  days,  after 
which  the  operation  is  repeated  over  another  portion  of  the 
turbinated  bodv.  These  applications  are  continued  until  the 
patency  of  the  passage  has  been  restored.  When  the  hyper- 
trophy  is  excessive  the  cold  wire  snare  may  be  used  to  re- 
move redundant  portions.  The  membrane  is  first  antesthet- 
ized  with  cocaine  and  the  loop  made  to  surround  the  mass. 
The  wire  is  then  drawn  into  the  tube  and  cuts  through  the 
tissue  which  it  surrounds.  When  the  mass  is  situated  in  the 
posterior  nares  the  wire  loop  should  be  made  to  cut  through 
slowly  by  using  the  screw.  In  this  manner  haemorrhage  is 
avoided.  As  cocaine  exsanguinates  the  membrane,  it  is  well 
to  use  only  a  sufficient  quantitv  to  produce  anaesthesia,  in 
order  that  the  snare  may  remove  as  much  of  the  swollen  mu- 
cous membrane  as  possible.  After  the  operation  is  completed 
a  little  iodol  is  to  be  insufflated  upon  the  cut  surface,  and  the 
patient  directed  to  avoid  forcible  efforts  at  clearing  the  nos- 
tril for  at  least  twelve  hours.  In  this  way  haemorrhage  is 
avoided,  and  prompt  recoverv  is  the  rule. 

Hygienic  rules,  such  as  proper  attention  to  underwear, 
the  daily  use  of  the  cold  bath,  etc.,  must  not  be  forgotten  in 
the  treatment  of  these  cases. 

Deformities  of  the  Nasal  Septum. 

As  the  condition  which  obstructive  lesions  of  this  char- 
acter produce  have  been  discussed  sufficiently  under  hvper- 
trophic  rhinitis,  we  shall  consider  here  onlv  the  surgical  pro- 
cedures adopted  for  the  relief  of  the  obstruction.  Where  the 
deformity  consists  of  a  prominent  ridge  extending  from  the 
anterior  portion  of  the  cavitv  for  a  considerable  distance 
toward  the  posterior  nares,  the  nasal  saw  devised  by  Bos- 
worth  seems  to  be  the  most  simple  instrument  for  relieving 
the  condition.  The  patencv  of  the  passage  is  to  be  restored 
by  sawing  off  the  obstructing  ledge  either  from  above  down- 
ward or  from  below  upward,  according  to  the  special  topog- 
raphy of  the  lesion  and   the  choice  of  the  operator.     This 


TREATMENT. 


625 


procedure  can  be  carried  out  under  cocaine  anaesthesia,  and 
is  absolutely  painless.  Care  should  be  taken  that  all  instru- 
ments used  at  the  operation  have  been  previously  sterilized 
by  boiling  in  a  one-per-cent  carbonate-of-soda  solution.  After 
the  operation,  a  little  iodol  is  insufflated  into  the  passage,  so 
as  to  cover  the  exposed  surface,  and  recovery  is  usually  un- 
eventful. 

Where  the  obstruction  is  of  such  a  shape  that  the  saw- 
can  not  be  used  the  galvano-cauterv  may  be  employed.  After 
local  anaesthesia  has  been  induced  by  the  use  of  cocaine,  the 
flat  platinum  blade  should  be  applied  to  the  most  prominent 
point  and  the  obstruction  burned  awav.  The  platinum  tip 
should  be  at  a  bright-red  heat,  as  a  temperature  below  this 
causes  pain,  while  if  it  is  heated  to  a  higher  degree  the  opera- 
tion is  likely  to  be  followed  by  hiemorrhage.  It  is  usually 
unwise  to  attempt  the  destruction  of  a  large  obstructing  mass 
at  one  sitting.  A  portion  of  the  obstruction  should  be  burned 
away,  and  the  operation  repeated  at  intervals  of  ten  days  or 
two  weeks  until  a  patent  passage  is  obtained.  The  wounded 
surface  is  dressed  in  the  same  manner  as  when  the  saw  is 
used. 


42 


CHAPTER    XLVl. 

ATROPHIC    RHINITIS. 

When  the  nasal  passages  are  the  seat  of  an  atrophic 
process  the  mucous  membrane  covering-  the  walls  of  the 
cavity  becomes  attenuated  and  applies  itself  closely  to  the 
underlying  bony  structures.  Microscopical  examination 
teaches  us  that  this  atrophy  affects  the  glands  with  which 
the  membrane  is  supplied.  The  secretion  is  altered  in  char- 
acter, and  contains  an  excess  of  solid  elements.  The  result 
is  that  it  dries  within  the  passage  forming  large  irregular 
crusts  upon  the  mucous  membrane.  As  these  crusts  become 
drv  they  shrink,  expelling  the  blood  from  the  underlying 
mucosa,  and  mechanically  augment  the  atrophic  changes. 
Bosworth  is  undoubtedly  correct  in  the  statement  that  the 
disease  is  of  long  duration  and  develops  as  the  result  of  puru- 
lent rhinitis  in  childhood,  usually  after  one  of  the  exanthe- 
mata. An  examination  shows  an  abnormal  patency  of  the 
nasal  passages,  the  membrane  applying  itself  so  closely  to 
the  bony  framework  that  the  turbinated  bodies  appear 
merely  as  lines  upon  the  outer  walls  of  the  chambers.  The 
post-pharyngeal  wall  can  be  easily  recognized  upon  anterior 
rhinoscopic  examination.  Owing  to  the  absence  of  the  nor- 
mal turbinated  tissue,  the  air  which  reaches  the  vault  of  the 
pharynx  through  the  nasal  cavity  is  not  properly  moistened 
and  abstracts  moisture  from  the  membrane  in  this  region  ; 
the  result  is  that  we  usually  find  a  mass  of  inspissated  mucus 
lining  the  vault  of  the  pharynx.  The  patient  comjilains  not 
only  of  the  crusts  which  are  expelled  Irom  the  nasal  cavity, 
but  also  of  the  formation  of  a  broad  scale  of  tenacious  mucus 
which  is  drawn  down  from  the  vault  of  the  pharynx  after 
repeated  efforts  at  clearing  the  passage.  These  masses  of 
inspissated  secretion  within  the  nasal  chambers  undergo  de- 
composition and  impart  to  the  breath  an  extremely  fetid  odor, 
which  is  a  characteristic  feature  of  the  affection. 

The  aural  S3mptoms  which  are  present  in  these  cases  are 

(626) 


PROGNOSIS— TREATMENT.  627 

ordinarily  insignificant,  and  arc  usually  due  to  a  previous  in- 
volvement of  the  middle  car  in  childhood,  when  the  purulent 
rhinitis  was  at  its  hcij^ht.  It  is  possible  that  the  imperfect 
moistening  of  the  air  may  play  a  part  in  the  production  of 
certain  aural  symptoms,  although  this  has  never  seemed  to 
me  probable.  It  is  more  likely  that  the  condition  within  the 
middle  ear  is  concomitant  with  rather  than  secondary  to  the 
nasal  condition. 

The  treatment  of  this  afTection  is  unsatisfactory  as  far  as 
effecting  a  permanent  cure,  but  etlficicnt  in  relieving  the  pa- 
tient from  the  disagreeable  symptoms  which  it  causes.  The 
tirst  measure  is  to  thoroughly  cleanse  the  nasal  cavit)',  remov- 
ing all  decomposing  crusts.  This  is  best  done  by  the  use  of 
the  nasal  douche.  At  least  a  quart  of  a  weak  saline  solution, 
as  hot  as  can  be  borne,  is  to  be  passed  through  the  nasal 
chambers  twice  daily  ;  this  not  only  washes  away  decompos- 
ing masses,  but  exercises  a  certain  stimulating  action  u[)on 
the  membranes.  During  the  day  the  nasal  chambers  may  be 
cleansed  at  frecpicnt  intervals  with  an  alkaline  spray  such  as 
the  following : 

Ijl   Sod.  bicarb gr.  xx  ; 

Acid,  boric 3  -"^s.  ; 

Acid,  carbolic iif.  iv  ; 

Glycerin 3  j  ; 

Aqua q.  s.  ad  5  viij. 

M.  Sig. :  Dilute  with  an  equal  volume  of  water,  and  use 
in  an  atomizer  as  a  nasal  spray. 

Later,  irrigation  ma\-  be  em[)love(l  hut  once  daily.  It 
faithfully  continued,  this  treatment  will  prevent  the  discom- 
fort attendant  uj)on  the  nasal  affection.  The  use  of  the  nasal 
douche  in  these  cases  seldom  |)roduces  aural  symptoms,  as 
the  nasal  passages  are  free  and  there  is  but  little  danger  of 
the  fluid  entering  the  tympanum.  It  should  always  be  re- 
membered in  employing  the  d(nichc  that  the  current  should 
enter  by  the  occluded  nostril  if  there  is  any  difference  in  the 
])atency  of  the  two  sides.  In  this  way  it  is  practically  imj)os- 
sible  for  any  accident  to  happen.  The  relief  of  the  nasal  con- 
dition exerts  but  little  influence  upon  the  aural  disease.  The 
chief  source  of  relief  is  probably  due  to  the  fact  that  the 
patient  makes  less  vigorous  efforts  at  expelling  the  crusts  by 
blowing  the  nose,  and  the  sudden  increase  of  tympanic  pres- 


528  ATROPHIC    RHINITIS. 

sure  is  thus  avoided.  In  some  instances  it  is  wise  to  fur- 
ther stimulate  the  parts  by  the  insufflation  of  the  following 
powder  immediately  after  the  douche  has  been  used: 

'^   Pulv.  sanguinariac 3  ss. ; 

Pulv.  lycopodii q.  s.  ad  3  j. 

This  causes  considerable  pain  when  insufflated  into  the  nasal 
chambers  and  produces  a  profuse  watery  discharge.  In  this 
manner  the  turbinated  tissues  are  stimulated  to  activity  and 
return  to  a  more  nearly  normal  condition.  The  insufflation 
of  the  powder  is  to  be  discontinued  after  the  tendency  to 
crust  formation  has  been  checked. 


CHAPTER   XLVII. 

ADENOID   VEGETATIONS. 

This  condition  is  undoubtedlv  responsible  for  more  than 
half  of  the  pathological  lesions  met  with  in  the  tympanum. 
It  is  essentially  a  disease  of  childhood,  probably  a  manifesta- 
tion of  a  constitutional  diathesis  not  inappropriately  termed 
by  Bosworth  "  Ivmphatism."  The  manner  in  which  a  mass 
of  lymphatic  tissue  in  the  pharyng^eal  vault  influences  the 
organ  of  hearing  has  already  been  described  in  the  beginning 
of  this  section,  and  need  not  be  repeated.  We  should  bear 
in  mind  that  its  influence  is  not  alone  confined  to  the  middle 
ear,  but  that  the  vessels  of  the  labyrinth  undoubtedly  suffer 
when  this  Ivmphatic  tissue  is  the  seat  of  repeated  attacks  of 
acute  inflammation. 

The  symptoms  dependent  upon  the  presence  of  the  growth 
are  those  of  nasal  obstructifMi.  the  sufTerer  breathing  almost 
entirelv  through  the  mouth,  especially  during  sleep.  The  na- 
sal qualitv  of  the  voice  is  wanting,  and  among  young  children 
there  is  a  persistent  discharge  from  the  anterior  nares.  Such 
a  growtii  becomes  easily  congested,  and  the  cases  present 
with  the  historv  of  frequent  colds  in  the  head.  A  cold  in  the 
head  in  a  child  under  twelve  years  of  age  is  almost  invariably 
dependent  upon  adenoid  vegetations  within  the  pharyngeal 
vault. 

The  aural  svmptoms  are  quite  as  characteristic  as  those 
referable  to  the  air  passages.  There  are  frecpient  attacks  of 
earache,  terminating  in  some  cases  in  a  discharge  from  the 
ear,  which  may  continue  as  a  purulent  otitis  media ;  or  where 
the  inflammation  is  less  severe  there  may  be  repeated  attacks 
of  tubo-tvmpanic  congestion  or  of  acute  catarrhal  otitis  media 
without  rupture  of  the  drum  membrane.  In  some  instances 
the  membrane  is  the  seat  of  a  minute  rupture,  and  there  is  the 
history  of  slight  serous  discharge  immediately  following  the 
attack,  but  disappearing  spontaneously  at  the  end  of  a  few 

days. 

(629) 


630 


ADENOID    VEGETATIONS. 


The  disturbances  of  function  arc  also  intermittent  in  char- 
acter. With  every  cold  in  the  head  the  hearing  becomes 
dull,  and,  if  the  patient  is  old  enough  to  explain  the  symp- 
toms, he  complains  of  a  full  or  stuffy  feeling  in  the  ears,  in 
addition  to  the  impaired  hearing.  Many  times  this  last  symp- 
tom is  misinterpreted  in  young  subjects,  and  the  child  is  con- 
sidered inattentive.  Such  a  history  should  always  lead  to  a 
careful  examination  of  the  ears,  as  most  children  who  seem 
to  be  "absent-minded  "  are  really  hard  of  hearing. 

An  examination  of  the  oro-pharynx  frequently  shows  that 
the  faucial  tonsils  are  enlarged,  although  they  may  be  normal 
in  size.  E^nlargcd  lymphatic  nodules  are  frequently  seen  ir- 
regularly distributed  upon  the  posterior  pharyngeal  wall,  and 
are  most  numerous  in  the  region  of  the  posterior  folds.  Upon 
posterior  rhinoscopy,  the  vault  of  the  pharynx  is  seen  to  be 
occupied  by  a  mass  attached  cither  to  the  roof  or  springing 
from  the  posterior  wall.  This  mass  may  be  most  prominent 
in  the  median  line,  or  the  membrane  covering  the  pharyngeal 
vault  may  be  uniformly  thickened,  excepting  in  the  region 
about  the  Eustachian  orifices,  where  it  is  thrown  into  numer- 
ous folds  and  reduplications.  The  membrane  covering  the 
entire  naso-pharyngeal  space  appears  velvety  and  soft,  resem- 
bling somewhat  the  faucial  tonsils  in  appearance,  although  the 
tissue  appears  less  firm.  Where  posterior  rhinoscopy  can 
not  be  conducted  satisfactorily,  such  a  growth  may  be  seen 
by  anterior  rhinoscopy  if  the  turbinated  bodies  have  been 
previously  exsanguinated  by  the  application  of  a  solution  of 
cocaine.  When  this  method  is  employed,  the  patient  should 
sit  so  that  the  floor  of  the  nasal  chambers  is  very  nearly  in 
the  horizontal  plane.  If  the  light  is  directed  into  the  cavity, 
the  adenoid  growth  will  be  seen  lying  behind  the  posterior  na- 
sal opening,  and  sometimes  encroaching  upon  it,  if  it  springs 
from  the  roof  of  the  naso-pharvnx.  When  attached  to  the 
posterior  wall,  it  is  recognized  by  the  undue  prominence  of 
this  region,  while  manipulation  with  a  probe  demonstrates  its 
papillary  character. 

In  very  young  children  either  of  these  methods  of  exami- 
nation may  be  impossible.  In  such  a  case  the  mouth  should 
be  held  open  either  with  a  mouth  gag  or  by  means  of  a  cork 
inserted  between  the  teeth,  and  the  surgeon  should  pass  the 
index  finger  behind  the  palate  into  the  naso-pharynx  ;  the 
presence  of  the  adenoid  vegetations  will  be  recognized  by 


OPERATI\'E    TREATMENT.  63  I 

the  soft,  velvety  feeling  of  the  membrane.  U[ion  withdraw- 
ing the  finger  it  will  be  usually  found  covered  with  blood,  as 
in  young  children  the  soft  tissue  is  easily  wounded. 

The  removal  of  such  a  mass  is  the  only  treatment  to  be 
considered  if  aural  s\niptoms  are  present.  The  author's 
preference  is  the  performance  of  a  complete  operatit)n  under 
general  anaesthesia,  the  growth  being  removed  bv  the  forceps 
and  curette. 

All  instruments  are  to  be  sterilized  by  boiling.  The  child 
is  placed  upon  the  table  in  a  recumbent  position.  For  chil- 
dren under  twelve  years  of  age  chloroform  is  without 
doubt  the  best  anaesthetic  to  employ.  After  complete  an- 
aesthesia the  head  is  thrown  backward  over  the  edge  of  the 
table,  or  the  same  end  can  be  attained  bv  placing  a  small, 
hard  pillow  under  the  neck.  Bv  this  i^ocedurc  the  vault  of 
the  pharynx  is  made  to  occupy  a  lower  level  than  the  larynx, 
and  the  danger  of  the  accidental  entrance  of  blood  into  the 
trachea  is  reduced  to  a  minimum.  The  jaws  are  held  apart 
by  a  properly  constructed  mouth  gag,  and  the  surgeon,  stand- 
ing upon  the  right  of  the  patient,  introduces  the  left  fore- 
finger behind  the  palate,  where  it  remains  until  the  operation 
is  completed.  The  closed  forceps  held  in  the  right  hand  is 
now  passed  along  the  left  forefinger  as  a  guide  into  the  naso- 
pharynx, where  it  is  opened  and  made  to  grasp  as  much 
of  the  growth  as  possible,  the  manipulation  being  directed 
by  the  kft  index  finger.  In  this  way  the  growth  is  removed 
piecemeal,  and  the  operation  is  not  considered  coruplete  luitil 
the  examining  finger  fails  to  discover  any  luasses  projecting 
into  the  nasopharyngeal  space.  The  operation  is  completed 
by  passing  the  curette  into  the  space  and  sweeping  it  along 
each  lateral  wall  and  along  the  posterior  wall  of  the  cavity. 
The  child  is  then  turned  over  on  the  face,  to  facilitate  the  dis- 
charge of  blood  which  has  accumulated  in  the  naso-pharynx 
during  the  progress  of  the  operation,  the  mouth  gag  not  be-, 
ing  removed  until  this  position  has  been  assumed.  No  after- 
treatment  is  necessary,  and,  if  the  instruments  have  been 
sterilized,  recovery  is  uneventful.  In  rare  cases  the  operation 
is  followed  by  an  acute  congestion  within  the  tympanum  or 
by  a  catarrhal  inflammation.  This  accident  happens  so  sel- 
dom that  it  can  be  practically  disregarded.  Another  com- 
plication which  is  perhaps  more  frequent  is  an  acute  follicular 
tonsillitis,  but  this  is  also  very  rare. 


6^2  ADENOID   VEGETATIONS. 

Intimately  associated  with  enlargement  of  the  pharyngeal 
tonsil  is  a  similar  condition  affecting  the  lymphatic  tissue 
of  the  oro-pharynx.  Many  years  ago  the  removal  of  en- 
larged faucial  tonsils  for  the  relief  of  impaired  hearing  was 
advocated  by  Yearsley.  After  Meyer  had  shown  the  marked 
effect  which  hypertrophy  of  the  pharyngeal  tonsil  exerted  in 
the  causation  of  inflammatory  processes  within  the  tympanum, 
removal  of  the  faucial  tonsils  for  these  conditions  fell  into  dis- 
use. It  is  probable  that  excision  of  the  faucial  tonsils  is  de- 
manded in  many  cases  of  aural  disease  both  of  the  suppura- 
tive and  of  the  nonsuppurative  variety.  It  is  also  probable 
that  the  beneficial  effect  produced  is  due  largely  to  the  ab- 
sorption of  the  pharyngeal  tonsil  which  follows  the  operation 
in  many  cases.  As  a  rule,  however,  whenever  the  faucial 
tonsils  are  hypertrophied.  and  at  the  same  time  an  inflam- 
matory process  is  present  within  the  tympanum,  their  re- 
moval should  be  advocated.  In  the  large  majority  of  cases 
enlarged  faucial  tonsils  occur  coincidcntly  with  an  enlarged 
pharyngeal  tonsil,  and  should  be  removed  at  the  same  time 
that  the  operation  is  performed  upon  the  adenoid  vegetations. 

In  subjects  under  the  age  of  twelve,  tonsillotomy  is  best 
performed  by  any  one  of  the  various  instruments  which  have 
been  devised  for  this  purpose.  The  author  prefers  Mathicus 
instrument,  but  any  of  the  others  are  probably  equally  efficient 
in  expert  hands. 

When  tonsillotomv  and  the  removal  of  adenoid  vegeta- 
tions are  practiced  at  the  same  operation,  it  is  usually  wise  to 
remove  the  faucial  tonsils  first,  as  the  heemorrhasre  from  the 
pharyngeal  vault  rather  obscures  the  field  of  operation  if  the 
adenoid  growth  is  first  attacked. 


CHAPTER    XLVIII. 

KASO-PHAKVNdKAI.   CATARRH. 

This  condition  is  probablv  due  t<i  atiophic  cliatii^^cs  which 
take  place  in  the  pharvnii^cal  tonsil  in  adult  life.  These 
cnang^es  consist  in  the  disappearance  of  the  cellular  elements 
of  the  lymphatic  nodules,  and  an  increase  in  the  fibrous  tissue 
constituting  the  framework  of  the  gland.  It  is  probable  that 
if  the  complete  history  of  every  case  could  be  obtained  we 
should  find  that  these  patients  suffered  from  symptoms  refer- 
able to  a  moderate  hypertrophy  of  the  pharyngeal  tonsil  dur- 
ing childhood.  The  condition,  however,' was  not  sufficiently 
marked  to  demand  surgical  interference,  and  in  early  adult 
life  the  symj)toms  disajipcarcd.  It  is  only  late  in  life,  when 
sclerotic  changes  take  place,  that  symptoms  dependent  upon 
the  presence  of  this  tissue  again  appear.  The  prominent 
symptom  of  which  these  patients  comj)lain  is  the  accumula- 
tion of  viscid  secretion  in  the  pharyngeal  vault.  This  secre- 
tion excites  re[)eatcd  cflorts  upon  the  |)art  of  the  patient  to 
draw  the  mass  back  into  the  mouth  and  exj^el  it  in  this  way. 
The  annoyance  which  the  condition  occasions  varies  greatly 
in  difTerent  individuals.  In  some,  the  effort  to  ex[)el  the  in- 
spissated mucus  niav  bring  on  an  attack  of  retching,  or  even 
vomiting,  while  in  other  instances  spasmodic  attacks  of  cough- 
ing may  be  excited.  All  manifestations  due  to  the  jjresence 
of  the  mass  arc  exaggerated  when  the  patient  suffers  from  a 
cold  in  the  head,  and  each  fresh  attack  of  inflammation  ren- 
ders the  victim  more  liable  to  a  succeeding  attack  upon  slight 
exposure. 

The  aural  svnij)toms  in  general  arc  those  enumerated  in 
the  chapter  upon  Chronic  Catarrhal  Otitis  Media.  We  may 
find  either  a  hvperplastic  or  a  hypertrophic  process  within 
the  middle  ear.  It  is  a  question  to  what  extent  the  naso- 
pharyngeal condition  has  been  productive  of  the  aural  lesion. 
My  own  belief  is  that  the  two  processes  are  coexistent  rather 
than  interdependent,  and  that  the  middle-ear  changes  have 

(633) 


634 


NASO-PHARYNGEAL   CATARRH. 


resulted  from  the  presence  of  an  excessive  amount  of  adenoid 
tissue  in  the  pharyngeal  vault  at  an  early  period  of  life,  and 
do  not  depend  upon  the  sclerotic  changes  which  have  subse- 
quently taken  place  in  this  tissue,  although  they  are  similar  in 
character.  Naturally  the  aural  symptoms  are  aggravated  by 
the  congestion  of  the  naso-pharyngeal  mucous  membrane,  on 
account  of  the  intimate  relation  which  exists  between  the 
vessels  in  the  two  regions  ;  but  it  is  unwarrantable  to  assume 
that  any  treatment  directed  toward  a  correction  of  the  naso- 
pharyngeal lesion  will  do  more  than  exempt  the  organ  of 
hearing  from  repeated  attacks  of  congestion.  The  sclerotic 
changes  have  advanced  to  such  an  extent  in  these  cases  that 
we  can  not  hope  for  an  absorption  of  the  new  tissue,  even  if 
the  parts  are  kept  in  a  state  of  perfect  equilibrium.  Efforts 
at  treatment  will  cut  short  an  attack  of  inflammation  in  this 
region  and  relieve  the  throat  symptoms,  and  will  at  the  same 
time  relieve  the  acute  aural  symptoms  and  cause  the  tym- 
panic mucous  membrane  to  return  to  the  condition  present 
before  the  acute  attack.  Bevond  this,  however,  no  treatment 
of  the  naso-pharynx  will  be  of  avail  in  adult  life. 

The  treatment  of  the  condition  consists  in  local  applica- 
tions of  an  astringent  solution  to  the  naso-pharyngeal  mucous 
membrane.  These  applications  may  be  made  by  means  of  a 
curved  applicator  carried  behind  the  soft  palate,  or,  as  I  pre- 
fer, by  a  cotton-tipped  probe  carried  through  the  anterior 
nares,  the  nasal  mucous  membrane  having  been  previously 
anaesthetized  with  cocaine.  The  strength  of  the  application 
should  vary  with  the  intensity  of  the  inflammation.  In  the 
early  stages  a  solution  of  nitrate  of  silver,  thirty  grains  to 
the  ounce,  thoroughly  applied  to  the  naso-pharvnx.  may  stop 
the  progress  of  the  attack  complctclv.  In  the  later  stages  a 
weaker  solution  should  be  emjiloycd.  For  the  chronic  con- 
dition relief  is  obtained  by  cleansing  the  naso-])harvngeal  mu- 
cous membrane  cither  by  the  post-nasal  syringe  or  bv  means 
of  a  spray  through  the  anterior  nares;  after  which  the  appli- 
cation of  a  solution  of  nitrate  of  silver,  ot  a  strength  of  from 
ten  to  fifteen  grains  to  the  ounce,  applied  in  the  manner 
already  described,  will  frequently  be  of  service  in  relieving 
the  discomfort  attendant  upon  the  condition. 


1  N  I)  i:x. 


Abscess,  cerebral,  459,  461,  530. 
diagnosis  of,  461. 
prognosis  of,  462. 
symptomalolog)'  of,  460. 
(reatment  of,  531. 
epidural,  529. 
extradural,  458. 
prognosis  of,  459. 
symptomatology  of,  458. 
treatment  of,  459. 
of  auricle,  2oi. 
Acoumcter  of  I'olitzer,  143. 

of  Urbantschitsch,  146. 
Adenoid  growths,  364,  629-631. 

tissue,  133. 
Adhesions,  division  of,  480,  48 1 . 
Adults,  symptoms  of  acute  calatrhal 

in,  325. 
Affections,  aural,  complicating,  592, 
acute  infectious  diseases,  591. 
diabetes,  599. 
gout,  599. 
leucncmia,  597. 
metastasis,  595. 
nephritis,  594. 
rheumatism,  599. 
special  drags,  (xm. 
tuberculosis,  596. 
dependent  upon  chronic  visceral 
ditions,  594. 
Ampulhv,  the,  40. 
Anccsthesia,  468. 
Anatomy  of  the  ear,  3. 
of  the  mastoid,  432. 
Angioma  of  the  auricle.  209. 
Anomalies  of  the  auricle,  173. 
of  the  antihelix,  174. 
of  the  aniitragus,  175. 
of  the  helix,  174. 
of  the  lobule,  174. 
of  the  tragus,  175. 


Antihelix,  anomalies  of  the,  174. 
Anton,  2o(^>. 
j  Antrum,  the,  437. 
]       mastoid,  the,  433,  434. 
Apparatus,  auditory,  concerted   action  of 
the.  66. 
conducting,  the,  4. 
surgery  of.  464,  465. 
lesions  of,  155. 
I  investment,  epithelial,  of,  22. 

I  diseases  of,  173 

Appendages,  auricular,  178,  179. 
Aqucductus  Kallopii.  the.  12. 
I  Arch,  Corti's,  41. 
'  Arteries,  the,  28,  29,  44. 
Artery,  cochlear,  the,  45. 
otitis  internal  auditory,  the,  44,  45. 

I       internal  maxill.ar)-,  the,  29. 
594  occipital,  the.  29. 

posterior  auricular,  the.  29. 
superficial  temporal,  the.  29. 
tympanic,  or  auriculaiis  profunda,   the, 

29,  30 
vestibular,  the,  45. 
vestibulo-cochlear,  the,  45. 
Articulation,     the    incuilo-stapcdial,    17. 
482. 

the  malleo-incudal,  17. 
con-         the  stapciio-vestibular,  17. 
Aspergillus  tlavus,  247. 

glaucus,  246. 
Atheroma  of  auricle,  201. 
Attollens  aurem,  the,  27. 
Attrahens  aurem,  the,  27. 
Audition,    disturbances    of,    in    hysteria, 
605. 
in  neurasthenia,  6(j2. 
Auditor)'  hyperesthesia,  71. 
Aural  polypus,  removal  of,  407. 
specula,  85. 

speculum,  improvised,  85. 
(63s) 


6i6 

Auricle,  the,  4,  50. 
abscess  of,  201. 

affections,  inflammatory,  of  200. 
angioma  of,  209. 

treatment  of,  2og. 
atheroma  of,  207. 

treatment  of,  208. 
cystoma  of,  210. 

treatment  of,  211. 
deformities  of,  174. 
diseases  of,  173. 

cutaneous,  of,  187. 
epithelioma  of,  213. 

treatment  of,  214,  215. 
erysipelas  of,  201. 
fibroma  of,  206. 

treatment  of,  207. 
framework,  cartilaginous,  of,  4. 
gangrene  of,  205. 

treatment  of,  205. 
hoematoma  of,  202. 

treatment  of,  203. 
lipoma  of,  207. 
malfonnations  congenital,  of,  173. 

treatment  of,  180. 
malposition,  of  the  entire,  176. 
ossification,  of,  204. 

treatment  of,  205. 
papilloma  of,  212. 
perichondritis  of,  200. 

treatment  of,  201. 
sarcoma  of,  216. 

treatment  of,  216. 
shape,  anomalous,  of,  176. 
treatment  of  injuries  of,  184. 
tumors,  benign,  of,  206. 

malignant,  of,  213. 
wounds  and  injuries  of,  183. 

treatment  of,  184. 
Auricular  appendages,  178,  179. 

artery,  the  posterior,  29. 
Auscultatory  sounds,  113. 

Bacon's  scarificator,  227. 
Bag,  air,  of  Politzer,  329. 
Bag,  Politzer's,  109. 
Baginsky,  59. 
Baratoux,  196. 
Barth,  145,  178. 
Basilaris,  membrana,  the,  41. 
Bergmann,  461. 
method  of,  526. 


INDEX. 


Bezold,  62,  150. 
Binder,  175. 

Bing,  experiment  of,  162. 
Blake,  26,  100,  144,  409. 
Blake's  middle-ear  syringe,  334. 
Bloodletting,  227. 
Boettecher,  44. 
Bone  conduction,  151. 
temporal,  the,  437. 
development  of,  8. 
Bony  canal,  the,  7. 
Bosworth,  135,  620,  624,  629. 
Botey,  100. 

Bougie,  Eustachian,  the,  309,  381. 
Brenner,  167. 
Brown-Sequard,  202. 
Bruit,  the  normal  tympanic,  114. 
Brunner,  202. 
Bryant,  26. 
Buck,  212,  356. 
Burnett,  180. 

Canal,  bony,  the,  7. 

bodies,  foreign,  in,  279. 
a-tiologv  of,  279. 
diagnosis  of,  281. 
pathology'  of,  279. 
prognosis  of,  281. 
symptomatology  of,  280. 
treatment  of,  2S2,  283. 

by  external  operation,  283. 
cochlear,  the,  37. 

Eustachian,   the,    297,    331,    365,    381, 
610. 
dilatation  of,  366. 
Fallopian  the,  12,  508. 
Canals,  semicircular,  the,  35,  60. 
Cantharidis  acetum,  application  of,  192. 
Cassebohm,  356. 
Catarrh,  Eustachian,  300,  306. 
naso-phanngeal,  633,  634. 
tubal,  300. 

aetiolog)-  of,  300. 
diagnosis  of,  302,  303. 

examination,  functional,  304.  305. 
examination,  physical,  302. 
pathology  of,  300. 
prognosis  of,  306. 
symptomatology  of,  301. 
treatment  of,  307,  309,  311. 
tubo-tympanic,  313.    See  Congestion, 

TUBO-TYMPANIC. 


INDEX. 


637 


Catheter,  Eustachian,  the,  107,  303,  307, 
308,  319,  335,  365,  386. 
introduction  of,  112. 
of  Noyes,  124. 
ordinary,  309. 
Pomeroy's  faucial,  125. 
Catheterization,  107,  ill. 
dangers  of,  I2g. 
methods  of,  119,  121. 
obstacles  to,  122,  123,  125,  127. 
value,  comparative,  of,  130,  131. 
Cavity,  tympanic,  the,  12,  13,  435. 

preparations    preliminary    to   opera- 
tions upon,  465. 
Cells,  hair,  the,  39. 
Cells  of  Deiters,  42. 
Cerebral  abscess,  459,  461,  530. 
diagnosis  of,  461. 
prognosis  of,  462. 
symptomatology  of,  460. 
treatment  of,  531. 
Cerumen,  impacted,  267,  280. 
wtiology  of,  2O7. 
diagnosis  of,  271. 
pathology  of,  268. 
prognosis  of,  272,  273. 
symptomatology  of,  269. 
treatment  of.  274,  275,  377. 
Chain,  ossicular,  the,  52. 

operations  involving,  470,  4S2. 
removal  of,  485. 
Changes  circulatory,  phenomena  depend- 
ent upon,  63. 
developmental,  437. 
Channel,  Eustachian,  120. 
Chateliier,  193. 

Cheyne-Slokes  respiration,  453. 
Children,   symptoms   of   acute    catarrhal 

otitis  in,  326,  327. 
Chimani,  2i:)9. 
Cholesteatoma,  391. 
development  of,  425. 
operation  for,  524. 
Cholewa,  231,  369,  477. 
Cleveland,  68. 
Cocaine,  use  of,  128. 
Cochlea,  the,  35,  57. 
function  of,  57,  59. 
membranous,  40,  41. 
Cochlear  artery,  the  45. 

canal,  the,  37. 
Coil,  Leiter,  the,  450. 


Cold,  229. 

Color  of  the  membrana  tympani,  92. 
Complications,  intracranial,  441. 
Concussion  of  the  labyrinth.  544. 
Conduction,  bone,  augmentation   of,  160. 
Congestion,  tubal,  300, 

x'tiology  of,  300. 

diagnosis  of,  303. 

examination,  functional,  304,  305. 
examination,  physical,  302. 

pathology  of,  3tx). 

prognosis  of,  306. 

symptomatology  of,  301. 

treatment  of,  307,  309,  311. 
tubo-tympanic,  313. 

ixiiology  of,  313. 

diagnosis  of,  315,  317. 

pathology  of,  313. 

prognosis  of,  318. 

symptomatology  of,  314. 

treatment  of,  319,  321. 
Corradi,  66. 
Corti,  arch  of,  41,  44.. 
fibres  of,  42. 
membrane  of,  43. 
rods  of,  41,  58. 
Cough,  reflex,  270. 
Cranial  contents,  relations  of,  435. 
Crista:  acusticx",  the,  40. 
Croupous  otitis,  external,  261. 
Curette,  use  of  the,  277. 
Cutogno,  recessus  of,  38. 

Deaf-mutism,  614. 

diagnosis  of.  616. 

pathology  of,  614. 

prognosis  of,  617. 

symptomatology  of,  616. 

treatment  of.  617. 
Heafness,  catarrhal,  351. 
Deiters,  cells  of,  42. 
Delstanche,  masseur  of,  381. 
De  Rossi,  1 89. 
Diabetes,  599. 
Diagnosis,  differential,  155. 
Diphtheria,  577. 

Diphtheritic  otitis,  external,  261. 
Disarticulation    at    the    incudo-stapcdial 

joint,  482. 
Diseases,  aural,  complicating,  590,  591. 

of  the  auricle,  173. 

of  the  external  canal,  217. 


638 


INDEX. 


Diseases,  of  the  mastoid,  439. 
of  the  middle  ear,  296. 
of  the  perceptive  mechanism,  535. 
Disturbances,  reflex  aural,  60S,  609,  612. 
prognosis  of,  611. 
treatment  of,  611. 
Division  of  adhesions,  481. 

about  stapes,  480. 
Dobell,  fluid  of,  365. 
Drainage,  349. 

Drum  membrane,  normal  appearance  of 
the,  92. 
recognition  of  the,  8g. 
retraction  of  the,  339,  377. 

Ear,  anatomy  of  the,  3,  4,  33. 
Darwinian,  the,  174. 
internal,  the,  34. 
middle,  diseases  of  the,  295. 
physiology  of  the,  48. 
preparation  of  the,  467. 
syringe,  234. 
Earache,  329, 
Ears,  frozen,  186. 
Eczema,  188,  189. 

treatment  of,  189,  191. 
Eitelberg's  test,  164,  169. 
Embolism,  labyrinthine,  551,  552. 
aetiology  of,  551. 
pathology  of,  551. 
prognosis  of,  552. 
symptomatology  of,  551. 
treatment  of,  552. 
Eustachian  tube,  the,  318. 
occlusion  of,  314,  316. 
Ewald,  61. 

Examination,  functional,    142,  317,    330, 
342,  362,  378,  379,  427. 
physical,   73,  315,  328,  329,  340,  358. 
361,  339,  377- 
obstacles  to,  95. 
technique  of,  the,  86,  87,  89. 
Extradural  abscess.     See  Abscess. 

Fallopii,  aqux'ductus,  the,  32, 438,  523,  570. 
Fever,  involvement  of  perceptive  appara- 
tus in  typhoid,  576. 
in  typhus,  576. 
Fibres  of  Trussak,  92. 
Fissure,  Glaserian,  the,  16,  18,  29,  33. 

Rivinian,  the,  248. 
Fistula,  auricular,  179. 
congenita  auris,  178. 


Flesch,  202. 
Fluid,  removal  of,  367. 
Folds,  intratympanic,  the,  25. 
Forceps,  McKay's  ear,  489. 
Fork,  tuning,  of  author,  148. 

of  Bezold,  157. 

of  Blake,  157. 
Forks,  tuning,  Hartmann's  series  of,  157, 

158. 
Fossa  of  Rosenmviller,  138. 
Fowler,  solution  of,  542. 
Fungus,  development  of  a,  241. 
Furuncle,  217. 

Gad,  54,  65. 

Galton  whistle,  the,   149,   150,   155,  156, 

15&.  159.  31S,  616,  617. 
modified,  157. 
Galvanic  reaction  of  the  auditory  nerve, 

167,  i6g. 
Ganglion,  Meckel's,  32. 
Gardiner  Brown,  154. 
Gelle's  test,  163. 

Gout,  aural  manifestations  of,  599. 
Gradinego,  146,  160,  165,  174. 

test  of,  164,  165,  169. 
Green,  194,477. 
Gruber,  230,  265,  475,  477. 
Gruening,  452. 

Haemorrhage,  labyrinthine,  548. 

£etiology  of,  54S. 

diagnosis  of,  549. 

pathology  of,  548. 

jirognosis  of,  550. 

sym|)tomalology  of,  549, 

treatment  of,  550. 
Hartmann.  21 1,  20o. 
tenotome  of,  477. 
tuning  forks  of,  157,  15S. 
Haug,  207. 
Hearing,  qualitative  determination  of,  155. 

quantitative  determination  of,  142. 
Heat,  231. 

Helix,  anomalies  of  the,  '74. 
Helmhnltz,  59. 

Ilensenii,  canalis  reuniens,  the,  37,  40. 
Herpes  of  the  auricle,  193. 

treatment  of,  194,  195. 
History,  the,  139-141. 
Homell's  method,  382. 
Hutchinson  teeth,  554. 


INDEX. 


639 


Hypenemia  of  the  labyrinth,  544. 
ct'tiology  of,  544. 
diagnosis  of,  545. 
pathology  of,  545. 
prognosis  of,  546. 
symptomatology  of,  545. 
treatment  of,  546. 
Hypercesthesia,  auditory,  71. 
Hyrtl,  476. 

Hysteria,  aural  manifestations  of,  605. 
diagnosis  of,  606. 
prognosis  of,  607. 
symptomatology  of,  605. 
treatment  of,  6:7. 

Incision  of  membrana  tympani,  319,  331, 

345,  469,  471,  473. 
Incus,  the,  17,  394. 
caries  of,  389. 

division  of  the  long  process  of,  4S2. 
ligaments  of,  18. 
obstacles  to  the  removal  of,  503,  505, 

507,  509. 
plastic  operations  upon,  4'<4. 
removal  of,  49 1,  41^3. 
Inflammation  tymjianic,  intracranial  com- 
plications of,  453. 
diagnosis  of,  454. 
prognosis  of,  454. 
symptomatology  of,  453. 
treatment  of,  454. 
Inflation,  307,  319,  365. 

methods  of,  103. 
Influenza,  epidemic,  efl"ect  upon   percep- 
tive apparatus,  577. 
Instillations,  229,  331. 
Instruments,  pro]iaratinn  of,  138,  139. 
Internal   maxillary,  tympanic  branch  of 

the,  29. 
Intertrigo,  1S7. 

treatment  of,  l83. 
Intracranial  involvement,  441,  443. 
Intratympanic  folds,  the,  25. 

soft  parts,   operations   involving    the, 
469. 
Investment,  epithelial,  of  the  conducting 

apparatus,  23. 
Irrigation,  333,  335. 

Jankau,  166,  167. 

Joint,  incudo-stapedial,  the,  17. 

disarticulation  at,  482. 
Jungken,  209. 


Kaflirs,  development  of  the  lobule  among 

the,  174. 
Kaiser,  39. 
Kessel,  4S5,  494, 
Kipp,  207,  2og. 
Knapp,  459. 
Konig's  rods,  150. 
Korner,  435,  462. 
Koscgarten,  386. 
Kretschmann,  506. 

Labyrinth,  the,  57. 
anaemia  of,  541. 
atiology  of,  541. 
diagnosis  of,  542. 

examination,  functional,  542. 
examination,  physical,  542. 
prognosis  of,  542. 
symptomatology  of,  541. 
treatment  of,  542. 
blood  supply  of,  44. 
bony,  the,  34,  35. 

effect  of  tympanic  changes  upon,  61, 63. 
hypenvmia  of,  544. 
arliology  of,  544. 
diagnosis  of,  545. 

examination,  functional,  545. 
examination,  physical,  545. 
pathology  of,  544. 
prognosis  of,  546. 
symptumatdlogy  of,  545. 
treatment  of,  546. 
inflammation,  acute  of,  in  acute  tym- 
panic inflammation,  569. 
aetiology  of,  569. 
diagnosis  of,  571. 

examination,  functional,  571. 
examination,  physical,  571. 
pathology  of,  569. 
prognosis  of,  572. 
symptomatology  of,  570. 
treatment  of,  572. 
inflammation,  acute  of,  in  acute  men- 
ingitis, 5S1. 
in  ei)idemic  meningitis,  577. 
in  mumps,  576. 
inflammation,  chronic  of,  secondary  to 
chronic  tympanic  disease,  557. 
diagnosis  of.  562. 

examination,  functional,  563. 
examination,  [ihysical,  562. 
prognosis  of,  564. 


640 


INDEX. 


Labyrinth,  symptomatology  of,  558,  559, 
561. 
treatment  of,  565,  567. 
inflammation,  chronic  of,  in  leucaemia, 

597- 
inflammation,  specific,  of,  553,  5!4- 
setiology  of,  553. 
diagnosis  of,  554. 
pathology  of,  553,  557. 
prognosis  of,  554. 
symptomatology  of,  553. 
treatment  of,  555. 
membranous,  the,  37. 
Labyrinthine    complications    of,  chronic 
hypertrophic  otitis  media,  355. 
degeneration,  379. 
fluid,  the,  429. 
haemorrhage,  54S. 
aetiology  of,  548. 
diagnosis  of,  549. 
pathology  of,  548. 
prognosis  of,  550. 
symptomatology  of,  549. 
treatment  of,  550. 
involvement,  374,  378,  3S5,  395. 
Lamina  spiralis,  tlie,  35. 
Landmarks  at  the  fundus  of  the  canal,  90. 
Landmarks,  intratympanic,  the,  360. 
Leech,  author's  artificial,  228. 
Leiter  coil,  228,  229,  253,  259,  346. 
Leucaemia,  597. 
Levator  palati,  the,  28. 
Ligament,  anterior,  of  the  malleus,  18. 
division  of,  479. 
external,  of  the  malleus,  18. 
posterior,  of  the  incus,  18. 

of  the  malleus,  18. 
superior,  of  the  malleus,  18. 
Ligaments,  interossicular,  the,  19. 
intratympanic,  the,  19. 
of  the  stapes,  19. 
Light,  the  source  of,  76,  77. 
Listerine,  365 

Lobule,  anomalies  of  the,  174. 
thickening  of  the,  204. 

treatment  of,  204. 
tumor,  sebaceous,  of  the,  208. 
Loewenberg,  218. 
Lucae,  165,  382,  486. 
bulb  of,  311. 
phonometer  of,  147. 
pressure  sound  of,  383. 


Ludcwig,  411,  412,  507,  5C9. 

Lupus  erythematosus  of  the  auricle,  I97. 

treatment  of,  198. 
vulgaris,  19S. 

treatment  of,  19S,  199. 
Lustre  of  the  drum  mcm))rane,  92. 
Lymphatics  of  the  conducting  apparatus, 

31- 
Lymphatism,  629. 

Macewen,  454,  462. 
Macula  acustica,  the,  39. 
Malleus,  the,  14. 

divi-ion  of  anterior  ligament  of,  479. 
ligaments  of  the,  17- 
removal  of  the,  489. 
rotation  of  the,  358. 
Manubrium  mallei,  the,  398. 

excision  of  a  portion  of,  482. 
Marian,  208. 
Massage,  3S2,  3S3. 
Mastoid,  the,  401. 
diploic,  433. 
di,<>cases  of,  432. 
involvement  of,  347. 
a-dema  over,  224. 
operation  upon,  515,  517. 

technique  of,  519,  521,  523,  525. 
the  pneumatic,  432. 
Mastoid  process,  anatomy  of  the,  432. 
diseases  of  the,  432. 
inflammation  of  the,  439. 
aetiology  of,  439. 
diagnosis  of,  445,  447. 
pathology  of,  440. 
prognosis  of,  44S. 
symptomatology  of,  442,  443. 
treatment  of,  449,  451. 
Mastoiditis,  primar)-,  439. 
Maxillar)-  artery,  the  internal,  29. 
Measures,  precautionary,  in  examination, 

159- 
Meatus,  the  bony,  9,  11. 

external  auditory,  diseases  of  the,  217. 
(See  Otitis,  kxikrnal.) 
exostoses  of  the,  285. 

aetiology  of,  285. 

diagnosis  of,  286. 

pathology  of,  285. 

prognosis  of,  2S7. 

symptomatolog)'  of,  286. 

treatment  of,  288,  289. 


INDEX. 


641 


Meatus,  epithelioma  of  the,  213. 
treatment  of,  214,  215. 
malignant  tumors  of  tlie,  213. 
sarcoma  of  the,  216. 
treatment  of,  216. 
the  cartilaginous,  6. 
Mechanism,  perceptive,  diseases  of  the, 

535.  537- 
involvement  of  the,  574,  57?,  5S1,  582. 

diagnosis  of,  575. 

in  acute  mcningiii';,  5S1. 

in  cpitlemic  meningitis,  577. 

in  mumps,  576. 

in  typhoid  fever,  576. 

in  typhus  fever,  576. 

pathology  of,  574. 

prognosis  of,  575. 

symptomatology  of,  575. 

treatment  of,  575. 
the  receptive,  33. 
Meiiia,  scala,  the,  40. 
Medical   Sciences,  Reference  Handbook 

of,  507. 
Membrana  ba^ilaris,  the,  41. 

rccticularis,  the,  43. 
Membrana  tympani,  the,  57,  91,  93. 
bulging  of,  317,  328.  341. 
depression  of,  358. 
destruction  of,  395. 
exci-ion  of  large  part  of,  4S2. 
function  of,  51. 
incision  of,  319,  331,  332,  345,  469-471, 

473- 
injuries  of,  291. 
aetiology  of,  291. 
diagnosis  of,  293. 
pathology  of,  291. 
prognosis  of,  294. 
symptomatology  of,  292. 
treatment  of,  29^,  2  >5. 
method  of  incising,  321,  472. 
mobility  of,  KX). 
multiple  incision  of,  475. 
operations  involving,  469,  470. 

plastic,   uniting    incus  or  stapes  to, 
484. 
pockets  of,  24. 
retraction  of,  383. 
rupture  of,  293. 
technique  of  removal  of,  486. 
Membrana  vibrans,  the,  c;9,  396. 
Membrane,  partially  destroyed,  technique 
43 


of  operation  for  excision  of  rem- 
nant, 500. 
Membrane,  reproduction  of  the,  497. 

treatment  of,  499. 
Meningitis,  acute,  involvement  of  percep- 
tive apparatu^  in,  581. 
diagnosis  of,  583. 

examination,  functional,  5S3. 
pathology  of,  581. 
prognosis  of,  584. 
symptomatology  of,  58 1. 
treatment  of,  584. 
epidemic,  cercbro-spinal,  577. 
diagnosis  of,  579. 

examination,  functional,  579. 
examination,  physical,  579. 
pathology  of,  577. 
prognosis  of,  579. 
symptomatology  of,  578. 
treatment  of,  580. 
otitic,  455. 
purulent,  532. 

treatment  of,  533. 
Metastasis,  595. 
Meyer,  632. 
Microti.!,  176,  177. 

Middle  ear,  treatment  of  discharge  from, 
409. 
operations  on  the,  465. 
classification  of,  469. 
i n St ni incuts  for,  466. 
treatment  after,  495. 
Miot,  484. 
Mirror,  reflecting,  the,  78,  81. 

rhinoscopic,  the,  138. 
Modiolus,  the,  35. 
Motion,  passive,  381. 
Mucous  membrane,  reduplications  of,  24. 
Mumps,  576. 

Muscles,  the  extrinsic,  27. 
function  of  the,  55. 
the  intratympanic,  27. 
the  intrinsic,  27. 
the  tubal,  28. 
Syringectomy,  partial,  474. 
Myringotomy,  4C9, 470. 
exploratory,  473. 
operation  of,  471. 

Naso-pharynx,  diseases  of  the,  618,  619. 

examination  of  the,  132. 
Nephritis,  aural  complications  of,  594. 


642 


INDEX. 


Nerve,  auditor}',  the,  45,  47. 
galvanic  reaction  of,  167. 
reaction  of,  to  stimuli,  65. 

auricularis  magnus,  the,  31. 

auriculo-temporal,  the,  31. 

cochlear,  the,  45. 

facial,  the,  31. 

trigeminus,  the,  31. 

vagus,  auricular  branch  of  the,  31. 

vestibular,  the,  46. 

Vidian,  the,  32. 
Nerves,  the  sensory,  31. 
Nervous  diseases,  effect  of,  5S6. 
Neurasthenia,    aural    manifestations    of, 
602. 

diagnosis  of,  603. 

prognosis  of,  605. 

treatment  of,  605. 
Nose,  diseases  of  the,  618,  619. 

examination  of  the,  132. 

Observations,    preliminary,    73,   75,    297^ 

299. 
Oliver,  68. 
Operation,  mastoid,  the,  515. 

preparation  of  the  field  of,  467. 
Operations,  middle-ear,  476. 
Orifices,  Eustachian,  the,  630. 
Ossicles,  the,  14,  15,  17,  398,  40S. 
function  of,  53. 
mobility  of,  100. 
removal  of,  485,  4S7. 
removal  of  individual,  485. 
technique  of  removal  of,  486. 

of  removal  of,  with  memhr.ina   tvni- 
pani  intact,  486. 
Ostmann,  24. 

Otitis     external     circumscribed,      acute, 
217. 
aetiology  of,  217. 
diagnosis  of,  221,  223. 
pathology  of,  218,  219. 
prognosis  of,  225. 
symptomatology  of,  219. 
treatment  of,  226,  227,  229,  231,  233, 
235- 
Otitis    external    circumscribed,    chronic, 

236,  237. 
.  .     incision  of,  233. 

internal  medication  of,  235. 
Otitis    external   croupous,  treatment   of, 
263. 


Otitis  external  diffuse,  acute,  255. 

aetiology  of,  255. 

diagnosis  of,  256,  257. 

pathology  of,  255. 

prognosis  of,  258. 

symptomatology  of,  256. 

treatment  of,  258,  259. 
Otitis  external  diffuse,  chronic,  238. 

cetiology  of,  23S,  239. 

diagnosis  of.  244,  245,  247. 

pathology  of,  239,  241. 

prognosis  of,  249. 

symptomatology  of,  242,  243. 

treatment  of,  250,  253,  257. 
diphtheritic  external,  treatment  of,  263. 
Otitis,  external,  hemorrhagic,  265. 

treatment  of,  266. 
Otitis  media,  acute  catarrhal,  323. 

aetiology  of,  323. 

diagnosis  of,  328,  329. 

pathology  of.  324,  325. 

prognosis  of,  330, 

sym])tomatology  of,  324,  327. 

treatment  of,  331,  333,  335. 
chronic,  351,  633. 

diagnosis  of,  376. 
Otitis  media,  chronic  hyperplastic,  372. 

aetiology  of,  372. 

diagnosis  of,  376,  377.  379. 
functional  examination,  378. 
physical  examination,  376. 

pathology  of,  373. 

prognosis  of,  3S0. 

symptomatology  of,  374.  375. 

treatment  of,  381,  383,  3S5. 
chronic  hypertrophic,  352. 

xtiology  of,  352,  353. 

diagnosis  of.  358.  359,  361. 
functional  examination,  362. 
physical  examination,  358. 

pathology  of,  354,  355. 

prognosis  of,  363. 

symptomatology  of,  356,  357. 

treatment    of,    364,    365,    367,    369, 

371- 
Otitis  media,  acute  purulent,  336. 
aetiology  of,  336. 
diagnosis  of,  340,  341. 
pathology  of,  337. 
prognosis  of,  343. 
sym]itomatology  of,  339. 
treatment  of,  344,  345.  347,  349. 


INDEX. 


643 


Otitis  media,  chronic  purulent,  3S8. 
cetiology  of,  388. 
diagnosis  of,  395,  397,  399. 
functional  examination,  399. 
physical  examination,  395,  397. 
pathology  of,  388-391. 
prognosis  of,  400,  401. 
symptomatology  of,  392,  393. 
treatment  of,  402. 
Otitis  media  purulenta  residua,  416. 
acute  cases,  416. 
aliology  of,  416. 
diagnosis  of,  418,  419. 
pathology  of,  416. 
prognosis  of,  419. 
symptomatology  of,  417. 
treatment  of,  420,  421. 
chronic  cases,  422. 
diagnosis  of,  426. 

functional  examination,  426. 
physical  examination,  426. 
pathology  of,  423. 
prognosis  of,  427. 
symptomatology  of,  425. 
treatment  of,  428,  429. 
Otoliths,  40. 

Otomycosis,  characteristics  of,  242. 
Otorrhtea,  therapeutic  measures  in,  415. 
operative  procedures  for,  411. 
temporary,  413. 
treatment  after  operation,  413. 
Otoscope,  the  pneumatic,  lOi,  361. 
Siegle's,  loi,  381-383. 

Palati,  levator,  the,  28. 

tensor,  the,  28. 
Panotitis,  569. 
Panesthesia,  71. 
Passages,  upper  air,  examination  of  the, 

133.  135.  137- 
Patient,  position  of  the,  469. 
Pemphigus,  193. 

treatment  of,  193. 
Perichondritis,  deformity  following,  200. 
Petrosal,  the  great  deep,  32. 

the  great  superficial,  32. 

the  small  deep,  32. 

the  small  superficial,  32. 
Pfliiger,  179. 
Pharyngeal  sounds,  iiS. 
Pharjnx,  examination  of,  132. 
Phenomena,  68. 


Phenomena,  irregular,  161. 

reflex,  67. 

secondary,  68,  69. 
Pierson's  solution,  542. 
Plexus,  tympanic,  the,  32. 
Plicotomy,  371,  476. 
Pocket  of  Troelsch,  342. 
Politzer,  265,  303,  305,  307,  312,  317,  319, 
321,  340,  356,  382.  3S6,  475,  477, 
479.  548,  557.  617. 
Politzerization    compared  with    catheter- 
ization, 131. 

comparative  value  of,  130. 
Polyotia,  180. 

treatment  of,  181. 
Polyp  aural,  differentiation  from,  338. 

removal  of,  406,  407. 
Pomeroy,  154,  359,  477. 
Pons  Varolii,  45. 

Powders,  in>ufllation  of,  405,  628. 
Prophylaxis,  311. 
Prussak,  31. 

chamber  of,  25. 

fibres  of,  23. 

space  of,  23. 

Quinine,  543. 

Randall,  435. 

Reissncr,  membrane  of,  37,  40. 

Respiration,  Cheyne-Stokcs,  453. 

Rctrahens  aurem,  the,  27. 

Reticularis,  the  membrana,  43. 

Rheumatism,     aural     complications     of, 

599- 
Rhinitis,  atrophic,  626,  627. 
Rhinitis,  hypertrophic,  620,  622,  623. 
Ridge,  temporal,  the,  436. 
Rinne,  experiment  of,  163,  304,  563. 

test  of,  163,  152,  153,  304. 
Kivinian  fissure,  the,  248. 

segment,  the,  97,  240,  336,  447. 
Rods,  of  Koenig,  150. 
Rohrer,  163. 
Roosa,  311. 

Rosenmiiller,  fosfa  of,  138. 
Riidinger,  38. 

Saccule,  the,  39. 

Salpingitis,  acute,  300.    See  CONGESTION, 

TUBAL. 

Santorini,  incisures  of,  7. 


644 


INDEX. 


Scale,  the  Gallon,  606. 

Scalpel,  515. 

Schimmelbusch,  218. 

Schubert,  174. 

Schwabach,  154. 

Schwartze,  358,  452,  477,  485. 

Septum   nasal,    deformities    of  the,   620, 

624,  625. 
Sexton,  499. 

Shrapnell,  membrane  of,  287,  293,   32S, 
342,  378,  396,  449,  488. 
incision  of,  472. 
Siebenmann,  144,  161,  251. 
Siegle's  otoscope,  loi,  3S1,  383. 
Sinus,  the  kteral,  435. 
thrombosis  of,  455,  528. 
diagnosis  of,  457. 
prognosis  of,  457. 
symptomatology  of,  456. 
treatment  of,  457,  529. 
Society,    transactions    of    the    American 

Otological,  512. 
Sound,  49. 

Sounds,  auscultatory,  113. 
pharyngeal,  118. 
tympanic,  114,  115. 
tubal,  116,  117. 
Specula,  aural,  83,  85. 
Speculum,  Bosworth's  nasal,  135. 

pneumatic,  the,  loi. 
Spray,  alkaline,  627. 
Stacke,  509,  526. 
Stapedectomy,  510,  511,  513. 

when  the  membrana  tympani  is  intact, 

510. 
when    the  membrane    is   partially  de- 
stroyed, 511. 
Stapedius,  the,  28. 
Stapes,  the,  17,  398,  401. 
disarticulation  of,  483. 
mobility  of,  384. 
mobilization  of,  482,  483. 
plastic  operations  upon,  4S2. 
region  of,  424. 
Steinbruegge,  160. 
Stetter,  174. 

Substances,  medicinal,  600. 
Support,    mechanical,    of   relaxed    mem- 
brana tympani,  371. 
Suppuration,  aural,  surgical  treatment  of 
the  intracranial    complications  of, 
527. 


Syphilis,  of  auricle,  195. 
treatment  of,  197. 

of  labyrinth,  553.     See  Labyrinth. 
Syringe,  Blake's  middle-ear,  334. 

hard-rubber  ear,  234. 
Syringing,  technique  of,  275,  403. 
.Szenes,  175. 

Taylor,  196. 

Tectoria,  the  membrana,  43. 
Teeth,  Hutchinson,  554. 
Temporal  ridge,  the,  436. 
Temporal,  the  superficial,  29. 
Tenotome,  Hartmann's,  477. 
Tensor  palati  muscle,  the,  28. 
tympani  muscle,  the,  27. 

tenotomy  of,  369,  476,  .^69,  477. 
Tests,  qualitative,  149. 

quantitative,  142,  143,  145,  147,  148. 
Teutleben,  24. 

Thiersch,   method    of  skin    grafting    of, 
215. 
solution  of,  368. 
Thrombosis,  labyrinthine,  551. 
PEtioiogy  of,  551. 
pathology,  of,  551. 
prognosis  of,  552. 
symptomatology  of,  551. 
treatment  of,  552. 
Thrombosis  of  lateral  sinus.    See  SiNUS. 
Tonsils,  faucial,  the,  365. 

enlarged,  404. 
Tongue  depressors,  137. 
Topography,  tympanic,  97,  99. 
Tragus,  anomalies  of  the,  175. 
Troeltsch,  pocket  of,  342. 
Tubal  congestion,  300.    See  Congestion. 

sounds,  116. 
Tube,  Eustachian,  the,  19,  138,  295,  308, 
309,  320,  323,  324,  336,  354,  355, 
357.  361,  367.  368,  370.  374.  381. 
3:9,  408,  428,  446,  486,  560,  595, 
596,  621. 
auscultation  of,  103. 
catheterization  of,  107. 
changes  in,  352,  358. 
closure  of,  305,  325. 
congestion  of,  161,  352. 
muscles  of,  28,  55. 
oedema  of,  161. 
walls  of,  357. 
Tuberculosis,  aural  lesion  in,  439,  596.* 


INDEX. 


645 


Tubo-tympanitis,  acute,  313.     See  CoN- 

C.KSTION,  TIHO-TYM PANIC. 

Tuning  fork,  the,  14S. 
of  author,  148. 
of  Blake,  157. 
series  of  Hartmann,  158. 
Turbinated  bodies,  the,  620. 

hypcrtrojihy  of,  364,  404,  620. 
treatment  of,  623. 
Tympanic  inflammation,  intracranial  com- 
plications of,  453. 
plexus,  32. 
sounds,  114. 
topography,  97. 
vault,  irrigation  of,  410. 
Tympani,  n.embrana,  the,  21. 

scala,  the,  45. 
Tympanum,  inflation    of  the,    102,    103, 
436. 

Urbantschitsch,  159,  169,  179,  218. 

electric  acoumetcr  of,  146. 
Utricle,  the,  39. 

\'alsalva's  method  of  inflation,  161,  .;2o. 
Vapors,  use  of,  3CH). 
Vault,  of  the  tympanum,  13. 
irrigation  of,  410. 


Vegetations,  adenoid,  629,  630,  631. 
Veins  of  the  conducting  mechanism,  30. 
Veins  of  the  labyrinth,  44. 
\'idian  nerve,  the,  30. 

Wagenshaiiser,  174,  194. 

Walb,  374. 

Wall,  internal  tympanic,  the,  12,  14. 

Weber,  154,  158. 

modification  of  experiment  of,  162. 
Weber,  F.  E.,  476. 
Wcber-I.iel,  369,  477. 
Weber's  test,  151. 
Weil.  202. 
Wharton  Jones,  69. 

Whistle,  the  llalton,  149,  150,   155,   156, 
318,  616,  617. 
author's  modification  of,  156. 
Wilde's  incision,  347,  422,  450. 
Willisii,  paracusis,  564,  583. 
Window,  the  oval,  424. 
Wounds,  contused,  of  auricle,  1S5. 
Wreden,  482. 

Vearsley,  632. 

Ziickcr,  195. 
Zttckcrkandl,  26,  30. 


TEXT-BOOK  OF 

OPHTHALMOSCOPY 

By  EDWARD  G.   LORING,   M.  D. 

Tjlt   I. 

The  Normal  Eye,  Determination  of  Rkkraction.  Diseases  oi   the 

Media,  Physioi.ogicai.  Optics,  and  Thiory  ok 

THE  Ophthalmoscope. 

Vjft   II. 

Edited  by  FRANCIS   H.   LoRING.   M.  D. 

Diseases  of  the  Retina,  Optic  Nerve,  and  Chorioid,  their 
Varieties  and  Compi  ications. 


MMr-KIC-IN   LANCET. 

"  This  is  a  beautiful  book,  the  handsomest  of  its  kinJ  on  this  subject 
ever  issued  from  an  American  press.  The  pajx-r,  press-work,  and  illustra- 
tions are  Kratilying  to  every  fu'tson  of  correct  tastes.  The  subject-matter 
is  of  such  excellence  as  to  be  worthy  of  this  beautiful  dress.  .  .  .  His 
style  IS  pleasant  and  easy.  Avoiding  the  Scylla  ol  too  much  technicality, 
he  has  not  plunged  into  the  Charybdis  of  loo  little.  He  will  be  doing  a 
proper  thing  who  adds  this  book  to  his  working  library." 

CLEyF.LAS'D   MEDICAL    GAZETTE. 

"  We  noticed  in  the  Gazette  tilt  fust  part  of  this  work,  which  ap- 
peared more  than  five  years  ago.  In  April,  1888,  the  talented  author 
suddenly  died,  We  feared  the  untimely  death  of  Dr.  Loring  would  pre- 
vent the  completion  of  this  work,  which,  on  the  whole,  is  the  most  credit- 
able on  ophthalmoscopy  yet  published  by  an  American  author;  but, 
fortunately,  he  hnd  already  made  notes  and  drawings  enougli  to  complete 
the  second  volume.  The  present  editor,  Dr.  K.  B.  Loring,  has  published 
the  work  almost  as  he  found  it  in  the  penciled  notes  of  the  author.  The 
book  before  us  is  characterized  by  the  original  drawings  and  elaboration 
of  clinical  cases  coming  under  the  observation  of  the  author,  which  charac- 
terized the  former  volume.  The  subjects  treated  in  this  part  are  diseases 
of  the  retina,  of  the  nerve,  and  of  the  chorioid,  their  varieties  and  com- 
plications." 


D.   APPLETON    AND    COMPANY,    NEW   YORK. 


A  New,  Thoroughly  Revised,  and  Enlarged  Edition  of 

QUAIN'S 
DICTIONARY  OF  MEDICINE. 

BV   VAR/OC'S   WRITERS. 

Edited  by  Sir  RICHARD   QUAIN,   B;irt.,  M.  D.,  LL.  D..  etc., 

Physician  Extraordinary  to  Her  Majisty  the  Qjceii ;  C'.'nsultin^  Physician  to  the   Hospital  for  Disea'^es 

of  the  Chest,  Bro.npton,  etc. 

Assisted  by  FREDERICK    THOMAS    ROBERTS,   M.  D.,  B.  Sc, 
Fellow  of  the  Koyal  College  of  Physicians,  etc. ; 

And  J.  MITCHELL   BRUCE,"M.A.,  M.  D., 

Fellow  of  the  Royal  College  of  Physicians,  etc. 

With  an  American  Appendix  by  SAMUEL  TREAT  ARMSTRONG,   Ph.  D.,  M.  D., 
Visiting  Physician  to  the  Harlem,  VVillard  Parker,  and  Riverside  Hospitals,  New  York. 


IN   TWO   VOLUMES.  Sold  only  by  subscription. 


This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  disea<;es  are  fully 
discussed  in  alphabetical  order.  The  description  of  each  includes  an  account  of  its  etioloijy 
and  anatomical  characters ;  its  symptoms,  course,  duration,  and  termination;  its  diagnosis, 
prognosis,  and,  lastly;  its  treatment.  General  Pathology  comprehends  articles  on  the  origin, 
characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies,  their  modes  of 
action,  and  on  the  methods  of  their  use.  The  articles  devoted  to  the  subject  of  Hygiene  treat 
of  the  causes  and  prevention  of  disease,  of  the  agencies  and  laws  affecting  public  health,  of 
the  means  of  preserving  th;  health  of  the  individual,  of  the  construction  and  management  of 
hospitals,  and  of  the  nursing  of  th^  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  respective 
headings,  both  in  aggregate  and  in  detail. 

The  American  Appendix  gives  more  definite  information  regarding  American  Mineral 
Springs,  and  adds  one  or  two  articles  on  particularly  American  topics,  besides  introducing 
some  recent  medical  terms  and  a  few  cro5s-rcferences. 

The  British  Medical  yournal  says  of  the  new  edition  : 

"The  original  purpose  which  actuated  the  preparation  of  the  original  edition  was,  to 
quote  the  words  of  the  preface  which  the  editor  has  written  for  the  new  edition,  '  a  desire  to 
place  in  the  hands  of  the  practitioner,  the  teachor,  and  the  student  a  means  of  ready  reference 
to  the  accumulated  knowledge  which  we  possessed  of  s:ientific  and  practical  medicine,  rapid 
as  was  its  progress,  and  difficult  of  access  as  were  its  scattered  records.'  The  scheme  of  the 
work  was  so  comorehensive,  the  selection  of  writers  so  judicious,  that  this  end  was  attained 
more  completely  than  the  most  sanguine  exp?ctations  of  the  able  editor  and  his  assistants 
could  have  anticipated.  ...  In  pre:iaring  a  new  edition  the  fart  had  to  be  faced  that  never 
in  the  history  of  medicine  had  progress  b33n  si  rapid  as  in  th?  last  twelve  years.  New  facts 
have  been  ascartained,  and  new  ways  of  looking  at  old  facts  have  come  to  be  recognized  as 
true.  .  .  .  The  revision  which  the  work  has  undergone  has  been  of  the  most  thorough  and 
judicious  character.  .  .  .  The  list  of  new  writers  numbers  fifty,  and  among  them  are  to  be 
found  tha  names  of  those  who  are  leading  authorities  upon  the  subjects  which  have  been 
committed  to  their  care." 


D.   ArPLETON    AND    COMPANY,    NKW    YORK. 


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